Sanjay Gupta, MD

In addition to sharing this handout (see PDF link) with your patients, Dr. Gupta also recommends advising them to watch the video Hand-washing Steps Using the WHO Technique, which is available at https://youtu.be/IisgnbMfKvI

In addition to sharing this handout (see PDF link) with your patients, Dr. Gupta also recommends advising them to watch the video Hand-washing Steps Using the WHO Technique, which is available at https://youtu.be/IisgnbMfKvI

In addition to sharing this handout (see PDF link) with your patients, Dr. Gupta also recommends advising them to watch the video Hand-washing Steps Using the WHO Technique, which is available at https://youtu.be/IisgnbMfKvI

The need for mental health services has never been greater. Unfortunately, many patients have limited access to psychiatric treatment, especially those who live in rural areas. Telepsychiatry—the delivery of psychiatric services through telecommunications technology, usually video conferencing—may help address this problem. Even before the onset of the coronavirus disease 2019 (COVID-19) pandemic, telepsychiatry was becoming increasingly common. A survey of US mental health facilities found that the proportion of facilities offering telepsychiatry nearly doubled from 2010 to 2017, from 15.2% to 29.2%.¹

In this article, we describe examples of where and how telepsychiatry is being used successfully, and its potential advantages. We discuss concerns about its use, its impact on the therapeutic alliance, and patients’ and clinicians’ perceptions of it. We also discuss the legal, technological, and financial aspects of using telepsychiatry. With an increased understanding of these issues, psychiatric clinicians will be better able to integrate telepsychiatry into their practices.

How and where is telepsychiatry being used

In addition to being used to provide psychotherapy, telepsychiatry is being employed for diagnosis and evaluation; clinical consultations; research; supervision, mentoring, and education of trainees; development of treatment programs; and public health. Telepsychiatry is an excellent mechanism to provide high-level second opinions to primary care physicians and psychiatrists on complex cases for both diagnostic purposes and treatment.

Evidence suggests that telepsychiatry can play a beneficial role in a variety of settings, and for a range of patient populations.

Emergency departments (EDs). Using telepsychiatry for psychiatric consultations in EDs could result in a quicker disposition of patients and reduced crowding and wait times. A survey of on-call clinicians in a pediatric ED found that using telepsychiatry for on-site psychiatric consultations decreased patients’ length of stay, improved resident on-call burden, and reduced factors related to physician burnout.² In this study, telepsychiatry use reduced travel for face-to-face evaluations by 75% and saved more than 2 hours per call day.²

Medical clinics. Using telepsychiatry to deliver cognitive-behavioral therapy significantly reduced symptoms of depression or anxiety among 203 primary care patients.³ Incorporating telepsychiatry into existing integrated primary care settings is becoming more common. For example, an integrated-care model that includes telepsychiatry is serving the needs of complex patients in a high-volume, urban primary care clinic in Colorado.⁴

Assertive Community Treatment (ACT) teams. Telepsychiatry is being used by ACT teams for crisis intervention and to reduce inpatient hospitalizations.⁵

Continue to: Correctional facilities

Correctional facilities. With the downsizing and closure of many state psychiatric hospitals across the United States over the last several decades, jails and prisons have become de facto mental health hospitals. This situation presents many challenges, including access to mental health care and the need to avoid medications with the potential for abuse. Using telepsychiatry for psychiatric consultations in correctional facilities can improve access to mental health care.

Geriatric patients. A systematic review of 76 studies evaluating telepsychiatry for older patients found this approach was well-accepted for inpatient and nursing home consultation, cognitive testing, dementia diagnosis and treatment, depression in integrated and collaborative care models, and psychotherapy.⁶ Another review of telepsychiatry for geriatric patients found that it supports mental health practice, especially when face-to-face therapy is not possible.⁷ The main drawbacks were technical problems and lack of support from staff.

Children and adolescents. The Michigan Child Collaborative Care (MC3) program is a telepsychiatry consultation service that has been able to provide cost-effective, timely, remote consultation to primary care clinicians who care for youth and perinatal women.⁸ New York has a pediatric collaborative care program, the Child and Adolescent Psychiatry for Primary Care (CAP PC), that incorporates telepsychiatry consultations for families who live >1 hour away from one of the program’s treatment sites.⁹

Patients with cancer. A literature review that included 9 studies found no statistically significant differences between standard face-to-face interventions and telepsychiatry for improving quality-of-life scores among patients receiving treatment for cancer.¹⁰

Patients with insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) is often recommended as a first-line treatment, but is not available for many patients. A recent study showed that CBT-I provided via telepsychiatry for patients with shift work sleep disorder was as effective as face-to-face therapy.¹¹ Increasing the availability of this treatment could decrease reliance on pharmacotherapy for sleep.

Patients with opioid use disorder (OUD). Treatment for patients with OUD is limited by access to, and availability of, psychiatric clinicians. Telepsychiatry can help bridge this gap. One example of such use is in Ontario, Canada, where more than 10,000 patients with concurrent opiate abuse and other mental health disorders have received care via telepsychiatry since 2008.¹²

Continue to: Increasing access to cost-effective care where it is needed most

Increasing access to cost-effective care where it is needed most

There is a crisis in mental health care in rural areas of the United States. A study assessing delivery of care to US residents who live in rural areas found these patients’ mental health–related quality of life was 2.5 standard deviations below the national mean.¹³ Additionally, the need for treatment is expected to rise as the number of psychiatrists falls. According to a 2017 National Council for Behavioral Health report,¹⁴ by 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists. While telepsychiatry cannot improve this shortage per se, it can help increase access to psychiatric services. The potential benefits of telepsychiatry for patients are summarized in Table 1.¹⁵

Telepsychiatry may be more cost-effective than traditional face-to-face treatment. A cost analysis of an expanding, multistate behavioral telehealth intervention program for rural American Indian/Alaska Native populations found substantial cost savings associated with telepsychiatry.¹⁶ In this analysis, the estimated cost efficiencies of telepsychiatry were more evident in rural communities, and having a multistate center was less expensive than each state operating independently.¹⁶

Most importantly, evidence suggests that treatment delivered via telepsychiatry is at least as effective as traditional face-to-face care. In a review that included >150 studies, Bashshur et al¹⁷ concluded, “Effective approaches to the long-term management of mental illness include monitoring, surveillance, mental health promotion, mental illness prevention, and biopsychosocial treatment programs. The empirical evidence … demonstrates the capability of [telepsychiatry] to perform these functions more efficiently and as well as or more effectively than in-person care.”

Clinician and patient attitudes toward telepsychiatry

Clinicians have legitimate concerns about the quality of care being delivered when using telepsychiatry. Are patients satisfied with treatment delivered via telepsychiatry? Can a therapeutic alliance be established and maintained? It appears that clinicians may have more concerns than patients do.¹⁸

A study of telepsychiatry consultations for patients in rural primary care clinics performed by clinicians at an urban health center found that patients and clinicians were highly satisfied with telepsychiatry.¹⁹ Both patients and clinicians believed that telepsychiatry provided patients with better access to care. There was a high degree of agreement between patients and clinician responses.¹⁹

Continue to: In a review of...

In a review of 452 telepsychiatry studies, Hubley et al²⁰ focused on satisfaction, reliability, treatment outcomes, implementation outcomes, cost effectiveness, and legal issues. They concluded that patients and clinicians are generally satisfied with telepsychiatry services. Interestingly, clinicians expressed more concerns about the potential adverse effects of telepsychiatry on therapeutic rapport. Hubley et al²⁰ found no published reports of adverse events associated with telepsychiatry use.

In a study of school-based telepsychiatry in an urban setting, Mayworm et al²¹ found that patients were highly satisfied with both in-person and telepsychiatry services, and there were no significant differences in preference. This study also found that telepsychiatry services were more time-efficient than in-person services.

A study of using telepsychiatry to treat unipolar depression found that patient satisfaction scores improved with increasing number of video-based sessions, and were similar among all age groups.²² An analysis of this study found that total satisfaction scores were higher for patients than for clinicians.²³

In a study of satisfaction with telepsychiatry among community-dwelling older veterans, 90% of participants reported liking or even preferring telepsychiatry, even though the experience was novel for most of them.²⁴

As always, patients’ preferences need to be kept in mind when considering what services can and should be provided via telepsychiatry, because not all patients will find it acceptable. For example, in a study of veterans’ attitudes toward treatment via telepsychiatry, Goetter et al²⁵ found that interest was mixed. Twenty-six percent of patients were “not at all comfortable,” while 13% were “extremely comfortable” using telepsychiatry from home. Notably, 33% indicated a clear preference for telepsychiatry compared to in-person mental health visits.

Continue to: Legal aspects of telepsychiatry

Legal aspects of telepsychiatry

When conducting telepsychiatry services, clinicians need to consider several legal issues, including federal and state regulations, as well as professional liability. In a 2017 article, Vanderpool²⁶ provided a comprehensive overview of the legal aspects of telepsychiatry. In March 2020, due to the COVID-19 pandemic, several key federal telehealth regulations were suspended. Telehealth service locations were broadened to allow patients to be interviewed at their homes. In addition, Health Insurance Portability and Accountability Act (HIPAA) requirements were loosened to allow for nonsecure communications with patients in certain settings. Box 1 highlights these changes and offers tips for using telepsychiatry during the COVID-19 pandemic.

Box 1

Licensure. State licensing and medical regulatory organizations consider the care provided via telepsychiatry to be rendered where the patient is physically located when services are rendered. Because of this, psychiatrists who use telepsychiatry generally need to hold a license in the state where their patients are located, regardless of where the psychiatrist is located.

Some states offer special telemedicine licenses. Typically, these licenses allow clinicians to practice across state lines without having to obtain a full professional license from the state. Be sure to check with the relevant state medical board where you intend to practice.

Because state laws related to telepsychiatry are continuously evolving, we suggest that clinicians continually check these laws and obtain a regulatory response in writing so there is ongoing documentation. For more information on this topic, see “Telepsychiatry during COVID-19: Understanding the rules” at MDedge.com/psychiatry.

Malpractice insurance. Some insurance companies offer coverage that includes the practice of telepsychiatry, whereas other carriers require the purchase of additional coverage for telepsychiatry. There may be additional requirements for practicing across state lines. Be sure to check with your insurer.

Continue to: Technical requirements and costs

In order to perform telepsychiatry, one needs Internet access, appropriate hardware such as a desktop or laptop computer or tablet, and a video conferencing application. Software must be HIPAA-compliant, although this requirement is not being enforced during the COVID-19 pandemic. Several popular video conferencing platforms were designed for or have versions suitable for telemedicine, including Zoom, Doxy.me, Vidyo, and Skype.

The use of different electronic health record (EHR) systems by various health care systems is a barrier to using telepsychiatry. One potential solution is to use a web portal, such as the one developed by East Carolina University’s North Carolina Statewide Telepsychiatry Program (NC-STeP), which connects hospital EDs and community-based primary care sites with remote psychiatric clinicians, allowing them to share secure electronic health information across different EHRs.²⁷Box 2 provides more details about this program.

Box 2

Our practice has extensive experience with telepsychiatry (Box 3), and for us, the specific costs associated with providing telepsychiatry services include maintenance of infrastructure and the purchase of hardware (eg, computers, smartphones, tablets), a video conferencing application (some free versions are available), EHR systems, and Internet access.

Box 3

Reimbursement for telepsychiatry

Private insurance reimbursement for treatment delivered via telepsychiatry obviously depends on the specific insurance company. Some facilities, such as nursing homes, hospitals, medical clinics, and correctional facilities, offer lump-sum fees to clinicians for providing contracted services. Some clinicians are providing telepsychiatry as direct-bill or concierge services, which require direct payment from the patient without any reimbursement from insurance.

Medicare Part B covers some telepsychiatry services, but only under certain conditions.²⁸ Previously, reimbursement was limited to services provided to patients who live in rural areas. However, on November 1, 2019, eligibility for telehealth services for Medicare Advantage (MA) recipients was expanded to include patients in both urban and rural locations. Patients covered by MA also can receive telehealth services from their home, instead of having to drive to a Centers for Medicare and Medicaid Services–qualified telehealth service center.

Continue to: Medicaid is the single...

Medicaid is the single largest payer for mental health services in the United States,²⁹ and all Medicaid programs reimburse for some telepsychiatry services. As with all Medicaid health care, fees paid for telepsychiatry are state-specific. Since 2013, several state Medicaid programs, including New York,³⁰ have expanded the list of eligible telehealth sites to include schools, thereby giving children virtual access to mental health clinicians.

Getting started

Clinicians who are interested in starting to provide treatment via telepsychiatry can begin by reviewing the American Psychiatric Association’s Telepsychiatry Toolkit at www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit. This toolkit, which is being continually updated, features numerous training videos for clinicians new to telepsychiatry, such as Learning To Do Telemental Health (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/learning-telemental-health) and The Credentialing Process (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/credentialing-process). Before starting, also consider reviewing the steps listed in Table 2.

Bottom Line

Evidence suggests telepsychiatry can be beneficial for a wide range of patient populations and settings. Most patients accept its use, and some actually prefer it to face-to-face care. Telepsychiatry may be especially useful for patients who have limited access to psychiatric treatment, such as those who live in rural areas. Factors to consider before incorporating telepsychiatry into your practice include addressing various legal, technological, and financial requirements.

Related Resources

• Von Hafften A. Telepsychiatry practice guidelines. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/practice-guidelines.
• Centers for Disease Control and Prevention. Telehealth and telemedicine: a research anthology of law and policy resources. https://www.cdc.gov/phlp/publications/topic/anthologies/anthologies-telehealth.html. Reviewed July 31, 2019.
• American Telemedicine Association. https://www.americantelemed.org/.

The need for mental health services has never been greater. Unfortunately, many patients have limited access to psychiatric treatment, especially those who live in rural areas. Telepsychiatry—the delivery of psychiatric services through telecommunications technology, usually video conferencing—may help address this problem. Even before the onset of the coronavirus disease 2019 (COVID-19) pandemic, telepsychiatry was becoming increasingly common. A survey of US mental health facilities found that the proportion of facilities offering telepsychiatry nearly doubled from 2010 to 2017, from 15.2% to 29.2%.¹

In this article, we describe examples of where and how telepsychiatry is being used successfully, and its potential advantages. We discuss concerns about its use, its impact on the therapeutic alliance, and patients’ and clinicians’ perceptions of it. We also discuss the legal, technological, and financial aspects of using telepsychiatry. With an increased understanding of these issues, psychiatric clinicians will be better able to integrate telepsychiatry into their practices.

How and where is telepsychiatry being used

In addition to being used to provide psychotherapy, telepsychiatry is being employed for diagnosis and evaluation; clinical consultations; research; supervision, mentoring, and education of trainees; development of treatment programs; and public health. Telepsychiatry is an excellent mechanism to provide high-level second opinions to primary care physicians and psychiatrists on complex cases for both diagnostic purposes and treatment.

Evidence suggests that telepsychiatry can play a beneficial role in a variety of settings, and for a range of patient populations.

Emergency departments (EDs). Using telepsychiatry for psychiatric consultations in EDs could result in a quicker disposition of patients and reduced crowding and wait times. A survey of on-call clinicians in a pediatric ED found that using telepsychiatry for on-site psychiatric consultations decreased patients’ length of stay, improved resident on-call burden, and reduced factors related to physician burnout.² In this study, telepsychiatry use reduced travel for face-to-face evaluations by 75% and saved more than 2 hours per call day.²

Medical clinics. Using telepsychiatry to deliver cognitive-behavioral therapy significantly reduced symptoms of depression or anxiety among 203 primary care patients.³ Incorporating telepsychiatry into existing integrated primary care settings is becoming more common. For example, an integrated-care model that includes telepsychiatry is serving the needs of complex patients in a high-volume, urban primary care clinic in Colorado.⁴

Assertive Community Treatment (ACT) teams. Telepsychiatry is being used by ACT teams for crisis intervention and to reduce inpatient hospitalizations.⁵

Continue to: Correctional facilities

Correctional facilities. With the downsizing and closure of many state psychiatric hospitals across the United States over the last several decades, jails and prisons have become de facto mental health hospitals. This situation presents many challenges, including access to mental health care and the need to avoid medications with the potential for abuse. Using telepsychiatry for psychiatric consultations in correctional facilities can improve access to mental health care.

Geriatric patients. A systematic review of 76 studies evaluating telepsychiatry for older patients found this approach was well-accepted for inpatient and nursing home consultation, cognitive testing, dementia diagnosis and treatment, depression in integrated and collaborative care models, and psychotherapy.⁶ Another review of telepsychiatry for geriatric patients found that it supports mental health practice, especially when face-to-face therapy is not possible.⁷ The main drawbacks were technical problems and lack of support from staff.

Children and adolescents. The Michigan Child Collaborative Care (MC3) program is a telepsychiatry consultation service that has been able to provide cost-effective, timely, remote consultation to primary care clinicians who care for youth and perinatal women.⁸ New York has a pediatric collaborative care program, the Child and Adolescent Psychiatry for Primary Care (CAP PC), that incorporates telepsychiatry consultations for families who live >1 hour away from one of the program’s treatment sites.⁹

Patients with cancer. A literature review that included 9 studies found no statistically significant differences between standard face-to-face interventions and telepsychiatry for improving quality-of-life scores among patients receiving treatment for cancer.¹⁰

Patients with insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) is often recommended as a first-line treatment, but is not available for many patients. A recent study showed that CBT-I provided via telepsychiatry for patients with shift work sleep disorder was as effective as face-to-face therapy.¹¹ Increasing the availability of this treatment could decrease reliance on pharmacotherapy for sleep.

Patients with opioid use disorder (OUD). Treatment for patients with OUD is limited by access to, and availability of, psychiatric clinicians. Telepsychiatry can help bridge this gap. One example of such use is in Ontario, Canada, where more than 10,000 patients with concurrent opiate abuse and other mental health disorders have received care via telepsychiatry since 2008.¹²

Continue to: Increasing access to cost-effective care where it is needed most

Increasing access to cost-effective care where it is needed most

There is a crisis in mental health care in rural areas of the United States. A study assessing delivery of care to US residents who live in rural areas found these patients’ mental health–related quality of life was 2.5 standard deviations below the national mean.¹³ Additionally, the need for treatment is expected to rise as the number of psychiatrists falls. According to a 2017 National Council for Behavioral Health report,¹⁴ by 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists. While telepsychiatry cannot improve this shortage per se, it can help increase access to psychiatric services. The potential benefits of telepsychiatry for patients are summarized in Table 1.¹⁵

Telepsychiatry may be more cost-effective than traditional face-to-face treatment. A cost analysis of an expanding, multistate behavioral telehealth intervention program for rural American Indian/Alaska Native populations found substantial cost savings associated with telepsychiatry.¹⁶ In this analysis, the estimated cost efficiencies of telepsychiatry were more evident in rural communities, and having a multistate center was less expensive than each state operating independently.¹⁶

Most importantly, evidence suggests that treatment delivered via telepsychiatry is at least as effective as traditional face-to-face care. In a review that included >150 studies, Bashshur et al¹⁷ concluded, “Effective approaches to the long-term management of mental illness include monitoring, surveillance, mental health promotion, mental illness prevention, and biopsychosocial treatment programs. The empirical evidence … demonstrates the capability of [telepsychiatry] to perform these functions more efficiently and as well as or more effectively than in-person care.”

Clinician and patient attitudes toward telepsychiatry

Clinicians have legitimate concerns about the quality of care being delivered when using telepsychiatry. Are patients satisfied with treatment delivered via telepsychiatry? Can a therapeutic alliance be established and maintained? It appears that clinicians may have more concerns than patients do.¹⁸

A study of telepsychiatry consultations for patients in rural primary care clinics performed by clinicians at an urban health center found that patients and clinicians were highly satisfied with telepsychiatry.¹⁹ Both patients and clinicians believed that telepsychiatry provided patients with better access to care. There was a high degree of agreement between patients and clinician responses.¹⁹

Continue to: In a review of...

In a review of 452 telepsychiatry studies, Hubley et al²⁰ focused on satisfaction, reliability, treatment outcomes, implementation outcomes, cost effectiveness, and legal issues. They concluded that patients and clinicians are generally satisfied with telepsychiatry services. Interestingly, clinicians expressed more concerns about the potential adverse effects of telepsychiatry on therapeutic rapport. Hubley et al²⁰ found no published reports of adverse events associated with telepsychiatry use.

In a study of school-based telepsychiatry in an urban setting, Mayworm et al²¹ found that patients were highly satisfied with both in-person and telepsychiatry services, and there were no significant differences in preference. This study also found that telepsychiatry services were more time-efficient than in-person services.

A study of using telepsychiatry to treat unipolar depression found that patient satisfaction scores improved with increasing number of video-based sessions, and were similar among all age groups.²² An analysis of this study found that total satisfaction scores were higher for patients than for clinicians.²³

In a study of satisfaction with telepsychiatry among community-dwelling older veterans, 90% of participants reported liking or even preferring telepsychiatry, even though the experience was novel for most of them.²⁴

As always, patients’ preferences need to be kept in mind when considering what services can and should be provided via telepsychiatry, because not all patients will find it acceptable. For example, in a study of veterans’ attitudes toward treatment via telepsychiatry, Goetter et al²⁵ found that interest was mixed. Twenty-six percent of patients were “not at all comfortable,” while 13% were “extremely comfortable” using telepsychiatry from home. Notably, 33% indicated a clear preference for telepsychiatry compared to in-person mental health visits.

Continue to: Legal aspects of telepsychiatry

Legal aspects of telepsychiatry

When conducting telepsychiatry services, clinicians need to consider several legal issues, including federal and state regulations, as well as professional liability. In a 2017 article, Vanderpool²⁶ provided a comprehensive overview of the legal aspects of telepsychiatry. In March 2020, due to the COVID-19 pandemic, several key federal telehealth regulations were suspended. Telehealth service locations were broadened to allow patients to be interviewed at their homes. In addition, Health Insurance Portability and Accountability Act (HIPAA) requirements were loosened to allow for nonsecure communications with patients in certain settings. Box 1 highlights these changes and offers tips for using telepsychiatry during the COVID-19 pandemic.

Box 1

Licensure. State licensing and medical regulatory organizations consider the care provided via telepsychiatry to be rendered where the patient is physically located when services are rendered. Because of this, psychiatrists who use telepsychiatry generally need to hold a license in the state where their patients are located, regardless of where the psychiatrist is located.

Some states offer special telemedicine licenses. Typically, these licenses allow clinicians to practice across state lines without having to obtain a full professional license from the state. Be sure to check with the relevant state medical board where you intend to practice.

Because state laws related to telepsychiatry are continuously evolving, we suggest that clinicians continually check these laws and obtain a regulatory response in writing so there is ongoing documentation. For more information on this topic, see “Telepsychiatry during COVID-19: Understanding the rules” at MDedge.com/psychiatry.

Malpractice insurance. Some insurance companies offer coverage that includes the practice of telepsychiatry, whereas other carriers require the purchase of additional coverage for telepsychiatry. There may be additional requirements for practicing across state lines. Be sure to check with your insurer.

Continue to: Technical requirements and costs

In order to perform telepsychiatry, one needs Internet access, appropriate hardware such as a desktop or laptop computer or tablet, and a video conferencing application. Software must be HIPAA-compliant, although this requirement is not being enforced during the COVID-19 pandemic. Several popular video conferencing platforms were designed for or have versions suitable for telemedicine, including Zoom, Doxy.me, Vidyo, and Skype.

The use of different electronic health record (EHR) systems by various health care systems is a barrier to using telepsychiatry. One potential solution is to use a web portal, such as the one developed by East Carolina University’s North Carolina Statewide Telepsychiatry Program (NC-STeP), which connects hospital EDs and community-based primary care sites with remote psychiatric clinicians, allowing them to share secure electronic health information across different EHRs.²⁷Box 2 provides more details about this program.

Box 2

Our practice has extensive experience with telepsychiatry (Box 3), and for us, the specific costs associated with providing telepsychiatry services include maintenance of infrastructure and the purchase of hardware (eg, computers, smartphones, tablets), a video conferencing application (some free versions are available), EHR systems, and Internet access.

Box 3

Reimbursement for telepsychiatry

Private insurance reimbursement for treatment delivered via telepsychiatry obviously depends on the specific insurance company. Some facilities, such as nursing homes, hospitals, medical clinics, and correctional facilities, offer lump-sum fees to clinicians for providing contracted services. Some clinicians are providing telepsychiatry as direct-bill or concierge services, which require direct payment from the patient without any reimbursement from insurance.

Medicare Part B covers some telepsychiatry services, but only under certain conditions.²⁸ Previously, reimbursement was limited to services provided to patients who live in rural areas. However, on November 1, 2019, eligibility for telehealth services for Medicare Advantage (MA) recipients was expanded to include patients in both urban and rural locations. Patients covered by MA also can receive telehealth services from their home, instead of having to drive to a Centers for Medicare and Medicaid Services–qualified telehealth service center.

Continue to: Medicaid is the single...

Medicaid is the single largest payer for mental health services in the United States,²⁹ and all Medicaid programs reimburse for some telepsychiatry services. As with all Medicaid health care, fees paid for telepsychiatry are state-specific. Since 2013, several state Medicaid programs, including New York,³⁰ have expanded the list of eligible telehealth sites to include schools, thereby giving children virtual access to mental health clinicians.

Getting started

Clinicians who are interested in starting to provide treatment via telepsychiatry can begin by reviewing the American Psychiatric Association’s Telepsychiatry Toolkit at www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit. This toolkit, which is being continually updated, features numerous training videos for clinicians new to telepsychiatry, such as Learning To Do Telemental Health (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/learning-telemental-health) and The Credentialing Process (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/credentialing-process). Before starting, also consider reviewing the steps listed in Table 2.

Bottom Line

Evidence suggests telepsychiatry can be beneficial for a wide range of patient populations and settings. Most patients accept its use, and some actually prefer it to face-to-face care. Telepsychiatry may be especially useful for patients who have limited access to psychiatric treatment, such as those who live in rural areas. Factors to consider before incorporating telepsychiatry into your practice include addressing various legal, technological, and financial requirements.

Related Resources

• Von Hafften A. Telepsychiatry practice guidelines. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/practice-guidelines.
• Centers for Disease Control and Prevention. Telehealth and telemedicine: a research anthology of law and policy resources. https://www.cdc.gov/phlp/publications/topic/anthologies/anthologies-telehealth.html. Reviewed July 31, 2019.
• American Telemedicine Association. https://www.americantelemed.org/.

The need for mental health services has never been greater. Unfortunately, many patients have limited access to psychiatric treatment, especially those who live in rural areas. Telepsychiatry—the delivery of psychiatric services through telecommunications technology, usually video conferencing—may help address this problem. Even before the onset of the coronavirus disease 2019 (COVID-19) pandemic, telepsychiatry was becoming increasingly common. A survey of US mental health facilities found that the proportion of facilities offering telepsychiatry nearly doubled from 2010 to 2017, from 15.2% to 29.2%.¹

In this article, we describe examples of where and how telepsychiatry is being used successfully, and its potential advantages. We discuss concerns about its use, its impact on the therapeutic alliance, and patients’ and clinicians’ perceptions of it. We also discuss the legal, technological, and financial aspects of using telepsychiatry. With an increased understanding of these issues, psychiatric clinicians will be better able to integrate telepsychiatry into their practices.

How and where is telepsychiatry being used

In addition to being used to provide psychotherapy, telepsychiatry is being employed for diagnosis and evaluation; clinical consultations; research; supervision, mentoring, and education of trainees; development of treatment programs; and public health. Telepsychiatry is an excellent mechanism to provide high-level second opinions to primary care physicians and psychiatrists on complex cases for both diagnostic purposes and treatment.

Evidence suggests that telepsychiatry can play a beneficial role in a variety of settings, and for a range of patient populations.

Emergency departments (EDs). Using telepsychiatry for psychiatric consultations in EDs could result in a quicker disposition of patients and reduced crowding and wait times. A survey of on-call clinicians in a pediatric ED found that using telepsychiatry for on-site psychiatric consultations decreased patients’ length of stay, improved resident on-call burden, and reduced factors related to physician burnout.² In this study, telepsychiatry use reduced travel for face-to-face evaluations by 75% and saved more than 2 hours per call day.²

Medical clinics. Using telepsychiatry to deliver cognitive-behavioral therapy significantly reduced symptoms of depression or anxiety among 203 primary care patients.³ Incorporating telepsychiatry into existing integrated primary care settings is becoming more common. For example, an integrated-care model that includes telepsychiatry is serving the needs of complex patients in a high-volume, urban primary care clinic in Colorado.⁴

Assertive Community Treatment (ACT) teams. Telepsychiatry is being used by ACT teams for crisis intervention and to reduce inpatient hospitalizations.⁵

Continue to: Correctional facilities

Correctional facilities. With the downsizing and closure of many state psychiatric hospitals across the United States over the last several decades, jails and prisons have become de facto mental health hospitals. This situation presents many challenges, including access to mental health care and the need to avoid medications with the potential for abuse. Using telepsychiatry for psychiatric consultations in correctional facilities can improve access to mental health care.

Geriatric patients. A systematic review of 76 studies evaluating telepsychiatry for older patients found this approach was well-accepted for inpatient and nursing home consultation, cognitive testing, dementia diagnosis and treatment, depression in integrated and collaborative care models, and psychotherapy.⁶ Another review of telepsychiatry for geriatric patients found that it supports mental health practice, especially when face-to-face therapy is not possible.⁷ The main drawbacks were technical problems and lack of support from staff.

Children and adolescents. The Michigan Child Collaborative Care (MC3) program is a telepsychiatry consultation service that has been able to provide cost-effective, timely, remote consultation to primary care clinicians who care for youth and perinatal women.⁸ New York has a pediatric collaborative care program, the Child and Adolescent Psychiatry for Primary Care (CAP PC), that incorporates telepsychiatry consultations for families who live >1 hour away from one of the program’s treatment sites.⁹

Patients with cancer. A literature review that included 9 studies found no statistically significant differences between standard face-to-face interventions and telepsychiatry for improving quality-of-life scores among patients receiving treatment for cancer.¹⁰

Patients with insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) is often recommended as a first-line treatment, but is not available for many patients. A recent study showed that CBT-I provided via telepsychiatry for patients with shift work sleep disorder was as effective as face-to-face therapy.¹¹ Increasing the availability of this treatment could decrease reliance on pharmacotherapy for sleep.

Patients with opioid use disorder (OUD). Treatment for patients with OUD is limited by access to, and availability of, psychiatric clinicians. Telepsychiatry can help bridge this gap. One example of such use is in Ontario, Canada, where more than 10,000 patients with concurrent opiate abuse and other mental health disorders have received care via telepsychiatry since 2008.¹²

Continue to: Increasing access to cost-effective care where it is needed most

Increasing access to cost-effective care where it is needed most

There is a crisis in mental health care in rural areas of the United States. A study assessing delivery of care to US residents who live in rural areas found these patients’ mental health–related quality of life was 2.5 standard deviations below the national mean.¹³ Additionally, the need for treatment is expected to rise as the number of psychiatrists falls. According to a 2017 National Council for Behavioral Health report,¹⁴ by 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists. While telepsychiatry cannot improve this shortage per se, it can help increase access to psychiatric services. The potential benefits of telepsychiatry for patients are summarized in Table 1.¹⁵

Telepsychiatry may be more cost-effective than traditional face-to-face treatment. A cost analysis of an expanding, multistate behavioral telehealth intervention program for rural American Indian/Alaska Native populations found substantial cost savings associated with telepsychiatry.¹⁶ In this analysis, the estimated cost efficiencies of telepsychiatry were more evident in rural communities, and having a multistate center was less expensive than each state operating independently.¹⁶

Most importantly, evidence suggests that treatment delivered via telepsychiatry is at least as effective as traditional face-to-face care. In a review that included >150 studies, Bashshur et al¹⁷ concluded, “Effective approaches to the long-term management of mental illness include monitoring, surveillance, mental health promotion, mental illness prevention, and biopsychosocial treatment programs. The empirical evidence … demonstrates the capability of [telepsychiatry] to perform these functions more efficiently and as well as or more effectively than in-person care.”

Clinician and patient attitudes toward telepsychiatry

Clinicians have legitimate concerns about the quality of care being delivered when using telepsychiatry. Are patients satisfied with treatment delivered via telepsychiatry? Can a therapeutic alliance be established and maintained? It appears that clinicians may have more concerns than patients do.¹⁸

A study of telepsychiatry consultations for patients in rural primary care clinics performed by clinicians at an urban health center found that patients and clinicians were highly satisfied with telepsychiatry.¹⁹ Both patients and clinicians believed that telepsychiatry provided patients with better access to care. There was a high degree of agreement between patients and clinician responses.¹⁹

Continue to: In a review of...

In a review of 452 telepsychiatry studies, Hubley et al²⁰ focused on satisfaction, reliability, treatment outcomes, implementation outcomes, cost effectiveness, and legal issues. They concluded that patients and clinicians are generally satisfied with telepsychiatry services. Interestingly, clinicians expressed more concerns about the potential adverse effects of telepsychiatry on therapeutic rapport. Hubley et al²⁰ found no published reports of adverse events associated with telepsychiatry use.

In a study of school-based telepsychiatry in an urban setting, Mayworm et al²¹ found that patients were highly satisfied with both in-person and telepsychiatry services, and there were no significant differences in preference. This study also found that telepsychiatry services were more time-efficient than in-person services.

A study of using telepsychiatry to treat unipolar depression found that patient satisfaction scores improved with increasing number of video-based sessions, and were similar among all age groups.²² An analysis of this study found that total satisfaction scores were higher for patients than for clinicians.²³

In a study of satisfaction with telepsychiatry among community-dwelling older veterans, 90% of participants reported liking or even preferring telepsychiatry, even though the experience was novel for most of them.²⁴

As always, patients’ preferences need to be kept in mind when considering what services can and should be provided via telepsychiatry, because not all patients will find it acceptable. For example, in a study of veterans’ attitudes toward treatment via telepsychiatry, Goetter et al²⁵ found that interest was mixed. Twenty-six percent of patients were “not at all comfortable,” while 13% were “extremely comfortable” using telepsychiatry from home. Notably, 33% indicated a clear preference for telepsychiatry compared to in-person mental health visits.

Continue to: Legal aspects of telepsychiatry

Legal aspects of telepsychiatry

When conducting telepsychiatry services, clinicians need to consider several legal issues, including federal and state regulations, as well as professional liability. In a 2017 article, Vanderpool²⁶ provided a comprehensive overview of the legal aspects of telepsychiatry. In March 2020, due to the COVID-19 pandemic, several key federal telehealth regulations were suspended. Telehealth service locations were broadened to allow patients to be interviewed at their homes. In addition, Health Insurance Portability and Accountability Act (HIPAA) requirements were loosened to allow for nonsecure communications with patients in certain settings. Box 1 highlights these changes and offers tips for using telepsychiatry during the COVID-19 pandemic.

Box 1

Licensure. State licensing and medical regulatory organizations consider the care provided via telepsychiatry to be rendered where the patient is physically located when services are rendered. Because of this, psychiatrists who use telepsychiatry generally need to hold a license in the state where their patients are located, regardless of where the psychiatrist is located.

Some states offer special telemedicine licenses. Typically, these licenses allow clinicians to practice across state lines without having to obtain a full professional license from the state. Be sure to check with the relevant state medical board where you intend to practice.

Because state laws related to telepsychiatry are continuously evolving, we suggest that clinicians continually check these laws and obtain a regulatory response in writing so there is ongoing documentation. For more information on this topic, see “Telepsychiatry during COVID-19: Understanding the rules” at MDedge.com/psychiatry.

Malpractice insurance. Some insurance companies offer coverage that includes the practice of telepsychiatry, whereas other carriers require the purchase of additional coverage for telepsychiatry. There may be additional requirements for practicing across state lines. Be sure to check with your insurer.

Continue to: Technical requirements and costs

In order to perform telepsychiatry, one needs Internet access, appropriate hardware such as a desktop or laptop computer or tablet, and a video conferencing application. Software must be HIPAA-compliant, although this requirement is not being enforced during the COVID-19 pandemic. Several popular video conferencing platforms were designed for or have versions suitable for telemedicine, including Zoom, Doxy.me, Vidyo, and Skype.

The use of different electronic health record (EHR) systems by various health care systems is a barrier to using telepsychiatry. One potential solution is to use a web portal, such as the one developed by East Carolina University’s North Carolina Statewide Telepsychiatry Program (NC-STeP), which connects hospital EDs and community-based primary care sites with remote psychiatric clinicians, allowing them to share secure electronic health information across different EHRs.²⁷Box 2 provides more details about this program.

Box 2

Our practice has extensive experience with telepsychiatry (Box 3), and for us, the specific costs associated with providing telepsychiatry services include maintenance of infrastructure and the purchase of hardware (eg, computers, smartphones, tablets), a video conferencing application (some free versions are available), EHR systems, and Internet access.

Box 3

Reimbursement for telepsychiatry

Private insurance reimbursement for treatment delivered via telepsychiatry obviously depends on the specific insurance company. Some facilities, such as nursing homes, hospitals, medical clinics, and correctional facilities, offer lump-sum fees to clinicians for providing contracted services. Some clinicians are providing telepsychiatry as direct-bill or concierge services, which require direct payment from the patient without any reimbursement from insurance.

Medicare Part B covers some telepsychiatry services, but only under certain conditions.²⁸ Previously, reimbursement was limited to services provided to patients who live in rural areas. However, on November 1, 2019, eligibility for telehealth services for Medicare Advantage (MA) recipients was expanded to include patients in both urban and rural locations. Patients covered by MA also can receive telehealth services from their home, instead of having to drive to a Centers for Medicare and Medicaid Services–qualified telehealth service center.

Continue to: Medicaid is the single...

Medicaid is the single largest payer for mental health services in the United States,²⁹ and all Medicaid programs reimburse for some telepsychiatry services. As with all Medicaid health care, fees paid for telepsychiatry are state-specific. Since 2013, several state Medicaid programs, including New York,³⁰ have expanded the list of eligible telehealth sites to include schools, thereby giving children virtual access to mental health clinicians.

Getting started

Clinicians who are interested in starting to provide treatment via telepsychiatry can begin by reviewing the American Psychiatric Association’s Telepsychiatry Toolkit at www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit. This toolkit, which is being continually updated, features numerous training videos for clinicians new to telepsychiatry, such as Learning To Do Telemental Health (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/learning-telemental-health) and The Credentialing Process (www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/credentialing-process). Before starting, also consider reviewing the steps listed in Table 2.

Bottom Line

Evidence suggests telepsychiatry can be beneficial for a wide range of patient populations and settings. Most patients accept its use, and some actually prefer it to face-to-face care. Telepsychiatry may be especially useful for patients who have limited access to psychiatric treatment, such as those who live in rural areas. Factors to consider before incorporating telepsychiatry into your practice include addressing various legal, technological, and financial requirements.

Related Resources

• Von Hafften A. Telepsychiatry practice guidelines. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/practice-guidelines.
• Centers for Disease Control and Prevention. Telehealth and telemedicine: a research anthology of law and policy resources. https://www.cdc.gov/phlp/publications/topic/anthologies/anthologies-telehealth.html. Reviewed July 31, 2019.
• American Telemedicine Association. https://www.americantelemed.org/.

There is a need for additional treatment options to improve symptoms, enhance the quality of life (QOL), and reduce suffering among patients who have chronic medical illness. Medical marijuana (MM) has the potential to help patients who have certain medical conditions in states where it is legal for prescription by a licensed medical provider.

Cannabis has a long history of medicinal use (Box 1^1-12). Two derivatives of the Cannabis plant—cannabinoid delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD)—are responsible for most of its effects. Some of these effects, including analgesia, decreased muscle spasticity, and reduced eye pressure, have been harnessed for their potential therapeutic effects (Box 2^13-19). As of November 2017, 29 states had legalized Cannabis for medical use, and several had legalized its recreational use.¹²

With the increasing availability of MM, psychiatrists are likely to encounter patients who are using it or who will ask them about it. This article reviews evidence related to using MM to treat patients with neuropathic pain; chemotherapyinduced nausea and vomiting (CINV); epilepsy; multiple sclerosis (MS); glaucoma; Crohn’s disease; Parkinson’s disease; amyotrophic lateral sclerosis; dementia-related behavioral disturbances; posttraumatic stress disorder (PTSD); and anxiety.

Box 1 
Cannabis: A history of medicinal use

Medical illnesses

Neuropathic pain. Chronic neuropathic pain affects an estimated 7% to 8% of adults.²⁰ Patients with neuropathic pain are often treated with anticonvulsants, anti­depressants, opioids, and local anesthetics²¹; however, these medications may not provide substantial relief. Research has revealed that THC and CBD can improve central and peripheral neuropathic pain, as well as pain associated with rheumatoid arthritis and fibromyalgia.²²

Wilsey et al²³ evaluated the analgesic effects of smoked MM for neuropathic pain in a small (N = 38) double-blind, randomized controlled trial (RCT). Patients in this study had a preexisting diagnosis of complex regional pain syndrome, spinal cord injury, peripheral neuropathy, or nerve injury. To prevent any unforeseen adverse outcomes related to Cannabis use, participants were required to have previous exposure to Cannabis. Patients were excluded if they had major mental illness, substance abuse, or other major medical ailments.

Participants smoked high-dose Cannabis cigarettes (7% THC), low-dose Cannabis cigarettes (3.5% THC), or placebo cigarettes. Pain was measured on a visual analog scale (VAS) that ranged from 0 (no pain) to 100 (worst possible pain). Compared with the placebo group, significant analgesia was achieved in both Cannabis groups (P = .016). The high-dose group had greater neurocognitive impairment.

Ware et al²⁴ conducted a crossover RCT (N = 23) to determine the efficacy of smoked MM for neuropathic pain. Participants had neuropathic pain for at least 3 months that was caused by trauma or surgery, with an average weekly pain intensity score >4 on scale of 0 to 10. Patients with pain due to cancer, nociceptive causes, unstable medical conditions, current substance abuse, history of a psychotic disorder, or suicidal ideation were excluded. Participants were assigned to a 9.4% THC group or a 0% THC group. Pain intensity was evaluated daily via telephone. Participants in the 9.4% THC group had statistically lower pain intensity compared with the 0% THC group (P = .023). Common adverse effects reported by those in the 9.4% group included headache, dry eyes, burning sensation, dizziness, numbness, and cough.

Box 2
The effects of Cannabis

In an RCT of vaporized Cannabis, 39 patients with a diagnosis of complex regional pain syndrome, thalamic pain, spinal cord injury, peripheral neuropathy, radiculopathy, or nerve injury were assigned to a medium-dose (3.53% THC), low-dose (1.29% THC), or placebo group.²⁵ Serious mental illness, substance abuse, and medical conditions were cause for exclusion. Participants received vaporized marijuana (average 8 to 12 puffs per visit) over 3 sessions. A 30% pain reduction was achieved by 26% of those in the placebo group, 57% of those in the low-dose group, and 61% of individuals in the high-dose group; the difference between placebo and each Cannabis group was statistically significant.

Chemotherapy-induced nausea and vomiting. Up to 80% of patients who receive chemotherapy experience CINV, which occurs from 24 hours to 7 days after receiving such therapy.²⁶ CINV negatively influences a patient’s QOL and may impact the decision to continue with chemotherapy. Use of MM can help to diminish vomiting by binding to central CB₁ receptors and averting the proemetic effects of dopamine and serotonin.²⁷ Two synthetically derived cannabinoids, dronabinol and nabilone, are FDA-approved for treating CINV.

In a small (N = 64) parallel-group RCT, Meiri et al²⁷ compared dronabinol with the commonly used antiemetic ondansetron and with a combination of dronabinol and ondansetron for treating CINV in adults. The primary outcome was prevention of delayed-onset CINV. Patients were eligible for this study if they had a malignancy that did not involve bone marrow, were receiving treatment with a moderately to highly emetogenic regimen, were not pregnant, and had an estimated life expectancy of at least 6 weeks after chemotherapy. The patients were randomized to 1 of 4 treatment groups: dronabinol alone, ondansetron alone, dronabinol plus ondansetron, or placebo. Overall, 47% to 58% of the active treatment groups improved, compared with 20% of the placebo group. Combination therapy did not provide any benefit beyond any single agent alone. All active treatments reduced nausea compared with placebo; there was no difference between active treatment groups. This study was limited by low enrollment.

Tramèr et al²⁸ conducted a systematic review of 30 randomized comparisons of MM with placebo or antiemetics. The reviewed studies were completed between 1975 to 1997 and analyzed a total of 1,366 patients. Nabilone was evaluated in 16 trials; dronabinol was utilized in 13 trials; and IM levonantradol, a synthetic cannabinoid analog of dronabinol, was used in 1 trial. These agents were found to be more effective as an antiemetic compared with prochlorperazine, metoclopramide, chlorpromazine, thiethyl­perazine, haloperidol, domperidone, or alizapride. In addition, 38% to 90% of patients in these studies preferred MM over the traditional antiemetics.

A Cochrane review²⁹ suggested that MM may be a viable option for treatment-resistant CINV; however, further studies are needed because current studies have methodological limitations.

Epilepsy. Maa and Figi³⁰ reported a case of a 5-year-old girl who had Dravet syndrome, which resulted in 50 generalized tonic-clonic seizures daily; multiple anticonvulsants did not alleviate these seizures. Because of her recurring seizures, the patient had multiple cognitive and motor delays and needed a feeding tube. In addition to her existing antiepileptic drug regimen, she was started on adjunctive therapy with a sublingual Cannabis extract containing a high concentration of CBD. Her seizures decreased from 50 per day to 2 to 3 nocturnal convulsions per month. The treatment enabled her to stop using a feeding tube, resume walking and talking, and sleep soundly.

dos Santos et al³¹ reviewed studies of MM for treating epilepsy. One was a double-blind, placebo-controlled trial that included 15 patients ages 14 to 49 who had secondary generalized epilepsy with a temporal lobe focus. Eight patients received 200 to 300 mg/d of oral CBD for 8 to 18 weeks, and 7 received placebo. Seven patients had fewer seizures and 4 had no seizures. Only 1 patient in the placebo group demonstrated any improvement. Another study in this review included 19 children with treatment-resistant epilepsy: Dravet syndrome (n = 13), Doose syndrome (n = 4), Lennox-Gastaut syndrome (n = 1), or idiopathic epilepsy (n = 1). These patients experienced various types of seizures with a frequency ranging from 2 per week to 250 per day. Overall, 84% of children treated with CBD had fewer seizures: 11% were seizure-free, 42% had a >80% reduction in seizures, and 32% had a 25% to 60% reduction in seizures. Parents also noted additional benefits, including increased attention, improved mood, and improved sleep. CBD was well tolerated in most patients in both studies.

Despite these results, a Cochrane review³² found that no reliable conclusions can be drawn regarding the efficacy of MM for treating epilepsy.

Multiple sclerosis. According to American Academy of Neurology guidelines, physicians may provide MM as an alternative treatment for patients with MS-related spasticity.³³ Multiple studies have tested MM and MM-related extracts for treating spasticity related to MS.^34,35 In a placebo-controlled crossover study, Corey-Bloom et al³⁴ reported a significant reduction in spasticity, measured using the modified Ashworth scale, in MS patients receiving Cannabis cigarettes vs placebo cigarettes (P < .0001). However, compared with the placebo group, patients who received MM had significant adverse effects, primarily cognitive impairment (P = .003).

In a multicenter RCT (N = 572 patients with refractory MS spasticity), Novotna et al³⁶ evaluated nabiximols, an oral mucosal spray of a formulated extract of Cannabis that contains THC and CBD in a 1:1 ratio. They assessed spasticity using the Numerical Spasticity Rating Scale (NRS). Results were confirmed by measuring the number of daily spasms, self-report of sleep quality, and activities of daily living. After 4 weeks of single-blind treatment, patients who responded to nabiximols (≥20% improvement in spasticity) were randomized to a placebo group or nabiximols group for 12 additional weeks. After 12 weeks, compared with those who received placebo, those in the nabiximols group experienced a statistically significant reduction in spasticity based on NRS score (P = .0002).
 

For a summary of evidence on MM for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis, see Box 3.^37-43

Box 3
Cannabis for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis

Psychiatric illnesses

Dementia-related behavioral disturbances. A few clinical trials with small sample sizes have found evidence supporting the use of MM compounds for alleviating neuropsychiatric symptoms of patients with dementia. An open-label pilot study of 6 individuals with late-stage dementia who received dronabinol, 2.5 mg/d, for 2 weeks, found a significant reduction (compared with baseline) in nighttime motor activity as measured with an actometer (P < .0028).⁴⁴ The secondary Neuropsychiatric Inventory (NPI) assessment found reductions in aberrant motor behavior (P = .042), agitation (P = .042), and nighttime behaviors (P = .42).

A 2014 retrospective analysis of 40 inpatients with dementia-related agitation and appetite loss who were treated with dronabinol (mean dosage: 7.03 mg/d) found reductions in all aspects of agitation, including aberrant vocalization, motor agitation, aggressiveness, and treatment resistance, as measured with the Pittsburgh Agitation Scale (P < .0001).⁴⁵ The study found no significant improvements in appetite, Global Assessment of Functioning mean score, or number of times patients awoke during the night. Adverse effects included sedation and delirium.

A RCT of 50 dementia patients with clinically relevant neuropsychiatric symptoms found no significant difference in mean NPI scores between patients given placebo and those who received nabiximols, 1.5 mg, 3 times daily.⁴⁶ There were no significant differences found in agitation, QOL, life activities, or caregiver-scored Caregiver Global Impression of Change scale.

In a small RCT, THC was safe and well tolerated in 10 older patients with dementia.⁴⁷ A 2009 Cochrane review⁴⁸ concluded that there was no evidence for the efficacy of MM in treating the neuropsychiatric symptoms related to dementia.

PTSD. Preclinical evidence shows that the endocannabinoid system is involved in regulating emotional memory. Evidence also suggests that cannabinoids may facilitate the extinction of aversive memories.^49,50

In 2009, New Mexico became the first state to authorize the use of MM for patients with PTSD. In a study of patients applying for the New Mexico Medical Cannabis Program, researchers used the Clinician Administered Posttraumatic Scale (CAPS) to assess PTSD symptoms.⁵¹ A retrospective chart review of the first 80 patients eval­uated found significant (P < .0001) reductions of several PTSD symptoms, including intrusive memories, distressing dreams, flashbacks, numbing and avoidance, and hyperarousal, in the group using MM vs those not using MM. There also was a significant difference in CAPS total score (P < .0001). Patients reported a 75% reduction in PTSD symptoms while using MM. This study has several limitations: It was a retrospective review, not an RCT, and patients were prescreened and knew before the study began that MM helped their PTSD symptoms.

In another retrospective study, researchers evaluated treatment with nabilone, 0.5 to 6 mg/d, in 104 incarcerated men with various major mental illnesses; most (91%) met criteria for Cannabis dependence.⁵² They found significant improvements in sleep and PTSD symptoms.

A double-blind RCT evaluated MM in 10 Canadian male soldiers with PTSD who experienced nightmares despite standard medication treatment. Adjunctive nabilone (maximum dose: 3 mg/d) resulted in a reduction in nightmares as measured by the CAPS recurrent distressing dream of the event item score.⁵³

Currently, there are no adequately powered RCTs of MM in a diverse group of PTSD patients. Most studies are open-label, enriched design, and included white male veterans. No well-conducted trials have evaluated patients with noncombat-related PTSD. Most of the relevant literature consists of case reports of Cannabis use by patients with PTSD.

Anxiety disorders.Patients frequently indicate that smoking Cannabis helps relieve their anxiety, although there is no replicated evidence based on double-blind RCTs to support this. However, in rat models CBD has been shown to facilitate extinction of conditioned fear via the endocannabinoid system.^54-56 The mechanism of action is not completely understood. CBD has been shown to have antagonistic action at CB₁ and CB₂ receptors. It may have similar effects on memory extinction and may be an adjunct to exposure therapies for anxiety disorders.

Das et al⁵⁷ studied the effects of CBD (32 mg) on extinction and consolidation of memory related to contextual fear in 48 individuals. They found that CBD can enhance extinction learning, and suggested it may have potential as an adjunct to extinction-based therapies for anxiety disorders.

Caveats: Adverse effects, lack of RCTs

Cannabis use causes impairment of learning, memory, attention, and working memory. Adolescents are particularly vulnerable to the effects of Cannabis on brain development at a time when synaptic pruning and increased myelination occur. Normal brain development could be disrupted. Some studies have linked Cannabis use to abnormalities in the amygdala, hippocampus, frontal lobe, and cerebellum. From 1995 to 2014, the potency of Cannabis (THC concentration) increased from 4% to 12%.⁵⁸ This has substantial implications for increased abuse among adolescents and the deleterious effects of Cannabis on the brain.

Heavy Cannabis use impairs motivation and could precipitate psychosis in vulnerable individuals. Cannabis use may be linked to the development of schizophrenia.⁵⁹

There are no well-conducted RCTs on the efficacy of MM, and adequate safety data are lacking. There is also lack of consensus among qualified experts. There is soft evidence that MM may be helpful in some medical conditions, including but not limited to CINV, neuropathic pain, epilepsy, and MS-related spasticity. Currently, the benefits of using MM do not appear to outweigh the risks.

Bottom Line

Limited evidence suggests medical marijuana (MM) may be beneficial for treating a few medical conditions, including neuropathic pain and chemotherapy-induced nausea and vomiting. There is no clear and convincing evidence MM is beneficial for psychiatric disorders, and Cannabis can impair cognition and attention and may precipitate psychosis. The risk of deleterious effects are greater in adolescents.

Related Resources

• Nguyen DH, Thant TM. Caring for medical marijuana patients who request controlled prescriptions. Current Psychiatry. 2017;16(8):50-51.
• National Institute on Drug Abuse. Marijuana as medicine. https://www.drugabuse.gov/publications/drugfacts/ marijuana-medicine.

Drug Brand Names

Alizapride • Litican, Superan
Chlorpromazine • Thorazine
Domperidone • Motilium
Dronabinol • Marinol, Syndros
Haloperidol • Haldol
Metoclopramide • Reglan
Nabilone • Cesamet
Nabiximols • Sativex
Ondansetron • Zofran, Zuplenz
Prochlorperazine • Compazine
Thiethylperazine • Torecan

There is a need for additional treatment options to improve symptoms, enhance the quality of life (QOL), and reduce suffering among patients who have chronic medical illness. Medical marijuana (MM) has the potential to help patients who have certain medical conditions in states where it is legal for prescription by a licensed medical provider.

Cannabis has a long history of medicinal use (Box 1^1-12). Two derivatives of the Cannabis plant—cannabinoid delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD)—are responsible for most of its effects. Some of these effects, including analgesia, decreased muscle spasticity, and reduced eye pressure, have been harnessed for their potential therapeutic effects (Box 2^13-19). As of November 2017, 29 states had legalized Cannabis for medical use, and several had legalized its recreational use.¹²

With the increasing availability of MM, psychiatrists are likely to encounter patients who are using it or who will ask them about it. This article reviews evidence related to using MM to treat patients with neuropathic pain; chemotherapyinduced nausea and vomiting (CINV); epilepsy; multiple sclerosis (MS); glaucoma; Crohn’s disease; Parkinson’s disease; amyotrophic lateral sclerosis; dementia-related behavioral disturbances; posttraumatic stress disorder (PTSD); and anxiety.

Box 1 
Cannabis: A history of medicinal use

Medical illnesses

Neuropathic pain. Chronic neuropathic pain affects an estimated 7% to 8% of adults.²⁰ Patients with neuropathic pain are often treated with anticonvulsants, anti­depressants, opioids, and local anesthetics²¹; however, these medications may not provide substantial relief. Research has revealed that THC and CBD can improve central and peripheral neuropathic pain, as well as pain associated with rheumatoid arthritis and fibromyalgia.²²

Wilsey et al²³ evaluated the analgesic effects of smoked MM for neuropathic pain in a small (N = 38) double-blind, randomized controlled trial (RCT). Patients in this study had a preexisting diagnosis of complex regional pain syndrome, spinal cord injury, peripheral neuropathy, or nerve injury. To prevent any unforeseen adverse outcomes related to Cannabis use, participants were required to have previous exposure to Cannabis. Patients were excluded if they had major mental illness, substance abuse, or other major medical ailments.

Participants smoked high-dose Cannabis cigarettes (7% THC), low-dose Cannabis cigarettes (3.5% THC), or placebo cigarettes. Pain was measured on a visual analog scale (VAS) that ranged from 0 (no pain) to 100 (worst possible pain). Compared with the placebo group, significant analgesia was achieved in both Cannabis groups (P = .016). The high-dose group had greater neurocognitive impairment.

Ware et al²⁴ conducted a crossover RCT (N = 23) to determine the efficacy of smoked MM for neuropathic pain. Participants had neuropathic pain for at least 3 months that was caused by trauma or surgery, with an average weekly pain intensity score >4 on scale of 0 to 10. Patients with pain due to cancer, nociceptive causes, unstable medical conditions, current substance abuse, history of a psychotic disorder, or suicidal ideation were excluded. Participants were assigned to a 9.4% THC group or a 0% THC group. Pain intensity was evaluated daily via telephone. Participants in the 9.4% THC group had statistically lower pain intensity compared with the 0% THC group (P = .023). Common adverse effects reported by those in the 9.4% group included headache, dry eyes, burning sensation, dizziness, numbness, and cough.

Box 2
The effects of Cannabis

In an RCT of vaporized Cannabis, 39 patients with a diagnosis of complex regional pain syndrome, thalamic pain, spinal cord injury, peripheral neuropathy, radiculopathy, or nerve injury were assigned to a medium-dose (3.53% THC), low-dose (1.29% THC), or placebo group.²⁵ Serious mental illness, substance abuse, and medical conditions were cause for exclusion. Participants received vaporized marijuana (average 8 to 12 puffs per visit) over 3 sessions. A 30% pain reduction was achieved by 26% of those in the placebo group, 57% of those in the low-dose group, and 61% of individuals in the high-dose group; the difference between placebo and each Cannabis group was statistically significant.

Chemotherapy-induced nausea and vomiting. Up to 80% of patients who receive chemotherapy experience CINV, which occurs from 24 hours to 7 days after receiving such therapy.²⁶ CINV negatively influences a patient’s QOL and may impact the decision to continue with chemotherapy. Use of MM can help to diminish vomiting by binding to central CB₁ receptors and averting the proemetic effects of dopamine and serotonin.²⁷ Two synthetically derived cannabinoids, dronabinol and nabilone, are FDA-approved for treating CINV.

In a small (N = 64) parallel-group RCT, Meiri et al²⁷ compared dronabinol with the commonly used antiemetic ondansetron and with a combination of dronabinol and ondansetron for treating CINV in adults. The primary outcome was prevention of delayed-onset CINV. Patients were eligible for this study if they had a malignancy that did not involve bone marrow, were receiving treatment with a moderately to highly emetogenic regimen, were not pregnant, and had an estimated life expectancy of at least 6 weeks after chemotherapy. The patients were randomized to 1 of 4 treatment groups: dronabinol alone, ondansetron alone, dronabinol plus ondansetron, or placebo. Overall, 47% to 58% of the active treatment groups improved, compared with 20% of the placebo group. Combination therapy did not provide any benefit beyond any single agent alone. All active treatments reduced nausea compared with placebo; there was no difference between active treatment groups. This study was limited by low enrollment.

Tramèr et al²⁸ conducted a systematic review of 30 randomized comparisons of MM with placebo or antiemetics. The reviewed studies were completed between 1975 to 1997 and analyzed a total of 1,366 patients. Nabilone was evaluated in 16 trials; dronabinol was utilized in 13 trials; and IM levonantradol, a synthetic cannabinoid analog of dronabinol, was used in 1 trial. These agents were found to be more effective as an antiemetic compared with prochlorperazine, metoclopramide, chlorpromazine, thiethyl­perazine, haloperidol, domperidone, or alizapride. In addition, 38% to 90% of patients in these studies preferred MM over the traditional antiemetics.

A Cochrane review²⁹ suggested that MM may be a viable option for treatment-resistant CINV; however, further studies are needed because current studies have methodological limitations.

Epilepsy. Maa and Figi³⁰ reported a case of a 5-year-old girl who had Dravet syndrome, which resulted in 50 generalized tonic-clonic seizures daily; multiple anticonvulsants did not alleviate these seizures. Because of her recurring seizures, the patient had multiple cognitive and motor delays and needed a feeding tube. In addition to her existing antiepileptic drug regimen, she was started on adjunctive therapy with a sublingual Cannabis extract containing a high concentration of CBD. Her seizures decreased from 50 per day to 2 to 3 nocturnal convulsions per month. The treatment enabled her to stop using a feeding tube, resume walking and talking, and sleep soundly.

dos Santos et al³¹ reviewed studies of MM for treating epilepsy. One was a double-blind, placebo-controlled trial that included 15 patients ages 14 to 49 who had secondary generalized epilepsy with a temporal lobe focus. Eight patients received 200 to 300 mg/d of oral CBD for 8 to 18 weeks, and 7 received placebo. Seven patients had fewer seizures and 4 had no seizures. Only 1 patient in the placebo group demonstrated any improvement. Another study in this review included 19 children with treatment-resistant epilepsy: Dravet syndrome (n = 13), Doose syndrome (n = 4), Lennox-Gastaut syndrome (n = 1), or idiopathic epilepsy (n = 1). These patients experienced various types of seizures with a frequency ranging from 2 per week to 250 per day. Overall, 84% of children treated with CBD had fewer seizures: 11% were seizure-free, 42% had a >80% reduction in seizures, and 32% had a 25% to 60% reduction in seizures. Parents also noted additional benefits, including increased attention, improved mood, and improved sleep. CBD was well tolerated in most patients in both studies.

Despite these results, a Cochrane review³² found that no reliable conclusions can be drawn regarding the efficacy of MM for treating epilepsy.

Multiple sclerosis. According to American Academy of Neurology guidelines, physicians may provide MM as an alternative treatment for patients with MS-related spasticity.³³ Multiple studies have tested MM and MM-related extracts for treating spasticity related to MS.^34,35 In a placebo-controlled crossover study, Corey-Bloom et al³⁴ reported a significant reduction in spasticity, measured using the modified Ashworth scale, in MS patients receiving Cannabis cigarettes vs placebo cigarettes (P < .0001). However, compared with the placebo group, patients who received MM had significant adverse effects, primarily cognitive impairment (P = .003).

In a multicenter RCT (N = 572 patients with refractory MS spasticity), Novotna et al³⁶ evaluated nabiximols, an oral mucosal spray of a formulated extract of Cannabis that contains THC and CBD in a 1:1 ratio. They assessed spasticity using the Numerical Spasticity Rating Scale (NRS). Results were confirmed by measuring the number of daily spasms, self-report of sleep quality, and activities of daily living. After 4 weeks of single-blind treatment, patients who responded to nabiximols (≥20% improvement in spasticity) were randomized to a placebo group or nabiximols group for 12 additional weeks. After 12 weeks, compared with those who received placebo, those in the nabiximols group experienced a statistically significant reduction in spasticity based on NRS score (P = .0002).
 

For a summary of evidence on MM for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis, see Box 3.^37-43

Box 3
Cannabis for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis

Psychiatric illnesses

Dementia-related behavioral disturbances. A few clinical trials with small sample sizes have found evidence supporting the use of MM compounds for alleviating neuropsychiatric symptoms of patients with dementia. An open-label pilot study of 6 individuals with late-stage dementia who received dronabinol, 2.5 mg/d, for 2 weeks, found a significant reduction (compared with baseline) in nighttime motor activity as measured with an actometer (P < .0028).⁴⁴ The secondary Neuropsychiatric Inventory (NPI) assessment found reductions in aberrant motor behavior (P = .042), agitation (P = .042), and nighttime behaviors (P = .42).

A 2014 retrospective analysis of 40 inpatients with dementia-related agitation and appetite loss who were treated with dronabinol (mean dosage: 7.03 mg/d) found reductions in all aspects of agitation, including aberrant vocalization, motor agitation, aggressiveness, and treatment resistance, as measured with the Pittsburgh Agitation Scale (P < .0001).⁴⁵ The study found no significant improvements in appetite, Global Assessment of Functioning mean score, or number of times patients awoke during the night. Adverse effects included sedation and delirium.

A RCT of 50 dementia patients with clinically relevant neuropsychiatric symptoms found no significant difference in mean NPI scores between patients given placebo and those who received nabiximols, 1.5 mg, 3 times daily.⁴⁶ There were no significant differences found in agitation, QOL, life activities, or caregiver-scored Caregiver Global Impression of Change scale.

In a small RCT, THC was safe and well tolerated in 10 older patients with dementia.⁴⁷ A 2009 Cochrane review⁴⁸ concluded that there was no evidence for the efficacy of MM in treating the neuropsychiatric symptoms related to dementia.

PTSD. Preclinical evidence shows that the endocannabinoid system is involved in regulating emotional memory. Evidence also suggests that cannabinoids may facilitate the extinction of aversive memories.^49,50

In 2009, New Mexico became the first state to authorize the use of MM for patients with PTSD. In a study of patients applying for the New Mexico Medical Cannabis Program, researchers used the Clinician Administered Posttraumatic Scale (CAPS) to assess PTSD symptoms.⁵¹ A retrospective chart review of the first 80 patients eval­uated found significant (P < .0001) reductions of several PTSD symptoms, including intrusive memories, distressing dreams, flashbacks, numbing and avoidance, and hyperarousal, in the group using MM vs those not using MM. There also was a significant difference in CAPS total score (P < .0001). Patients reported a 75% reduction in PTSD symptoms while using MM. This study has several limitations: It was a retrospective review, not an RCT, and patients were prescreened and knew before the study began that MM helped their PTSD symptoms.

In another retrospective study, researchers evaluated treatment with nabilone, 0.5 to 6 mg/d, in 104 incarcerated men with various major mental illnesses; most (91%) met criteria for Cannabis dependence.⁵² They found significant improvements in sleep and PTSD symptoms.

A double-blind RCT evaluated MM in 10 Canadian male soldiers with PTSD who experienced nightmares despite standard medication treatment. Adjunctive nabilone (maximum dose: 3 mg/d) resulted in a reduction in nightmares as measured by the CAPS recurrent distressing dream of the event item score.⁵³

Currently, there are no adequately powered RCTs of MM in a diverse group of PTSD patients. Most studies are open-label, enriched design, and included white male veterans. No well-conducted trials have evaluated patients with noncombat-related PTSD. Most of the relevant literature consists of case reports of Cannabis use by patients with PTSD.

Anxiety disorders.Patients frequently indicate that smoking Cannabis helps relieve their anxiety, although there is no replicated evidence based on double-blind RCTs to support this. However, in rat models CBD has been shown to facilitate extinction of conditioned fear via the endocannabinoid system.^54-56 The mechanism of action is not completely understood. CBD has been shown to have antagonistic action at CB₁ and CB₂ receptors. It may have similar effects on memory extinction and may be an adjunct to exposure therapies for anxiety disorders.

Das et al⁵⁷ studied the effects of CBD (32 mg) on extinction and consolidation of memory related to contextual fear in 48 individuals. They found that CBD can enhance extinction learning, and suggested it may have potential as an adjunct to extinction-based therapies for anxiety disorders.

Caveats: Adverse effects, lack of RCTs

Cannabis use causes impairment of learning, memory, attention, and working memory. Adolescents are particularly vulnerable to the effects of Cannabis on brain development at a time when synaptic pruning and increased myelination occur. Normal brain development could be disrupted. Some studies have linked Cannabis use to abnormalities in the amygdala, hippocampus, frontal lobe, and cerebellum. From 1995 to 2014, the potency of Cannabis (THC concentration) increased from 4% to 12%.⁵⁸ This has substantial implications for increased abuse among adolescents and the deleterious effects of Cannabis on the brain.

Heavy Cannabis use impairs motivation and could precipitate psychosis in vulnerable individuals. Cannabis use may be linked to the development of schizophrenia.⁵⁹

There are no well-conducted RCTs on the efficacy of MM, and adequate safety data are lacking. There is also lack of consensus among qualified experts. There is soft evidence that MM may be helpful in some medical conditions, including but not limited to CINV, neuropathic pain, epilepsy, and MS-related spasticity. Currently, the benefits of using MM do not appear to outweigh the risks.

Bottom Line

Limited evidence suggests medical marijuana (MM) may be beneficial for treating a few medical conditions, including neuropathic pain and chemotherapy-induced nausea and vomiting. There is no clear and convincing evidence MM is beneficial for psychiatric disorders, and Cannabis can impair cognition and attention and may precipitate psychosis. The risk of deleterious effects are greater in adolescents.

Related Resources

• Nguyen DH, Thant TM. Caring for medical marijuana patients who request controlled prescriptions. Current Psychiatry. 2017;16(8):50-51.
• National Institute on Drug Abuse. Marijuana as medicine. https://www.drugabuse.gov/publications/drugfacts/ marijuana-medicine.

Drug Brand Names

Alizapride • Litican, Superan
Chlorpromazine • Thorazine
Domperidone • Motilium
Dronabinol • Marinol, Syndros
Haloperidol • Haldol
Metoclopramide • Reglan
Nabilone • Cesamet
Nabiximols • Sativex
Ondansetron • Zofran, Zuplenz
Prochlorperazine • Compazine
Thiethylperazine • Torecan

There is a need for additional treatment options to improve symptoms, enhance the quality of life (QOL), and reduce suffering among patients who have chronic medical illness. Medical marijuana (MM) has the potential to help patients who have certain medical conditions in states where it is legal for prescription by a licensed medical provider.

Cannabis has a long history of medicinal use (Box 1^1-12). Two derivatives of the Cannabis plant—cannabinoid delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD)—are responsible for most of its effects. Some of these effects, including analgesia, decreased muscle spasticity, and reduced eye pressure, have been harnessed for their potential therapeutic effects (Box 2^13-19). As of November 2017, 29 states had legalized Cannabis for medical use, and several had legalized its recreational use.¹²

With the increasing availability of MM, psychiatrists are likely to encounter patients who are using it or who will ask them about it. This article reviews evidence related to using MM to treat patients with neuropathic pain; chemotherapyinduced nausea and vomiting (CINV); epilepsy; multiple sclerosis (MS); glaucoma; Crohn’s disease; Parkinson’s disease; amyotrophic lateral sclerosis; dementia-related behavioral disturbances; posttraumatic stress disorder (PTSD); and anxiety.

Box 1 
Cannabis: A history of medicinal use

Medical illnesses

Neuropathic pain. Chronic neuropathic pain affects an estimated 7% to 8% of adults.²⁰ Patients with neuropathic pain are often treated with anticonvulsants, anti­depressants, opioids, and local anesthetics²¹; however, these medications may not provide substantial relief. Research has revealed that THC and CBD can improve central and peripheral neuropathic pain, as well as pain associated with rheumatoid arthritis and fibromyalgia.²²

Wilsey et al²³ evaluated the analgesic effects of smoked MM for neuropathic pain in a small (N = 38) double-blind, randomized controlled trial (RCT). Patients in this study had a preexisting diagnosis of complex regional pain syndrome, spinal cord injury, peripheral neuropathy, or nerve injury. To prevent any unforeseen adverse outcomes related to Cannabis use, participants were required to have previous exposure to Cannabis. Patients were excluded if they had major mental illness, substance abuse, or other major medical ailments.

Participants smoked high-dose Cannabis cigarettes (7% THC), low-dose Cannabis cigarettes (3.5% THC), or placebo cigarettes. Pain was measured on a visual analog scale (VAS) that ranged from 0 (no pain) to 100 (worst possible pain). Compared with the placebo group, significant analgesia was achieved in both Cannabis groups (P = .016). The high-dose group had greater neurocognitive impairment.

Ware et al²⁴ conducted a crossover RCT (N = 23) to determine the efficacy of smoked MM for neuropathic pain. Participants had neuropathic pain for at least 3 months that was caused by trauma or surgery, with an average weekly pain intensity score >4 on scale of 0 to 10. Patients with pain due to cancer, nociceptive causes, unstable medical conditions, current substance abuse, history of a psychotic disorder, or suicidal ideation were excluded. Participants were assigned to a 9.4% THC group or a 0% THC group. Pain intensity was evaluated daily via telephone. Participants in the 9.4% THC group had statistically lower pain intensity compared with the 0% THC group (P = .023). Common adverse effects reported by those in the 9.4% group included headache, dry eyes, burning sensation, dizziness, numbness, and cough.

Box 2
The effects of Cannabis

In an RCT of vaporized Cannabis, 39 patients with a diagnosis of complex regional pain syndrome, thalamic pain, spinal cord injury, peripheral neuropathy, radiculopathy, or nerve injury were assigned to a medium-dose (3.53% THC), low-dose (1.29% THC), or placebo group.²⁵ Serious mental illness, substance abuse, and medical conditions were cause for exclusion. Participants received vaporized marijuana (average 8 to 12 puffs per visit) over 3 sessions. A 30% pain reduction was achieved by 26% of those in the placebo group, 57% of those in the low-dose group, and 61% of individuals in the high-dose group; the difference between placebo and each Cannabis group was statistically significant.

Chemotherapy-induced nausea and vomiting. Up to 80% of patients who receive chemotherapy experience CINV, which occurs from 24 hours to 7 days after receiving such therapy.²⁶ CINV negatively influences a patient’s QOL and may impact the decision to continue with chemotherapy. Use of MM can help to diminish vomiting by binding to central CB₁ receptors and averting the proemetic effects of dopamine and serotonin.²⁷ Two synthetically derived cannabinoids, dronabinol and nabilone, are FDA-approved for treating CINV.

In a small (N = 64) parallel-group RCT, Meiri et al²⁷ compared dronabinol with the commonly used antiemetic ondansetron and with a combination of dronabinol and ondansetron for treating CINV in adults. The primary outcome was prevention of delayed-onset CINV. Patients were eligible for this study if they had a malignancy that did not involve bone marrow, were receiving treatment with a moderately to highly emetogenic regimen, were not pregnant, and had an estimated life expectancy of at least 6 weeks after chemotherapy. The patients were randomized to 1 of 4 treatment groups: dronabinol alone, ondansetron alone, dronabinol plus ondansetron, or placebo. Overall, 47% to 58% of the active treatment groups improved, compared with 20% of the placebo group. Combination therapy did not provide any benefit beyond any single agent alone. All active treatments reduced nausea compared with placebo; there was no difference between active treatment groups. This study was limited by low enrollment.

Tramèr et al²⁸ conducted a systematic review of 30 randomized comparisons of MM with placebo or antiemetics. The reviewed studies were completed between 1975 to 1997 and analyzed a total of 1,366 patients. Nabilone was evaluated in 16 trials; dronabinol was utilized in 13 trials; and IM levonantradol, a synthetic cannabinoid analog of dronabinol, was used in 1 trial. These agents were found to be more effective as an antiemetic compared with prochlorperazine, metoclopramide, chlorpromazine, thiethyl­perazine, haloperidol, domperidone, or alizapride. In addition, 38% to 90% of patients in these studies preferred MM over the traditional antiemetics.

A Cochrane review²⁹ suggested that MM may be a viable option for treatment-resistant CINV; however, further studies are needed because current studies have methodological limitations.

Epilepsy. Maa and Figi³⁰ reported a case of a 5-year-old girl who had Dravet syndrome, which resulted in 50 generalized tonic-clonic seizures daily; multiple anticonvulsants did not alleviate these seizures. Because of her recurring seizures, the patient had multiple cognitive and motor delays and needed a feeding tube. In addition to her existing antiepileptic drug regimen, she was started on adjunctive therapy with a sublingual Cannabis extract containing a high concentration of CBD. Her seizures decreased from 50 per day to 2 to 3 nocturnal convulsions per month. The treatment enabled her to stop using a feeding tube, resume walking and talking, and sleep soundly.

dos Santos et al³¹ reviewed studies of MM for treating epilepsy. One was a double-blind, placebo-controlled trial that included 15 patients ages 14 to 49 who had secondary generalized epilepsy with a temporal lobe focus. Eight patients received 200 to 300 mg/d of oral CBD for 8 to 18 weeks, and 7 received placebo. Seven patients had fewer seizures and 4 had no seizures. Only 1 patient in the placebo group demonstrated any improvement. Another study in this review included 19 children with treatment-resistant epilepsy: Dravet syndrome (n = 13), Doose syndrome (n = 4), Lennox-Gastaut syndrome (n = 1), or idiopathic epilepsy (n = 1). These patients experienced various types of seizures with a frequency ranging from 2 per week to 250 per day. Overall, 84% of children treated with CBD had fewer seizures: 11% were seizure-free, 42% had a >80% reduction in seizures, and 32% had a 25% to 60% reduction in seizures. Parents also noted additional benefits, including increased attention, improved mood, and improved sleep. CBD was well tolerated in most patients in both studies.

Despite these results, a Cochrane review³² found that no reliable conclusions can be drawn regarding the efficacy of MM for treating epilepsy.

Multiple sclerosis. According to American Academy of Neurology guidelines, physicians may provide MM as an alternative treatment for patients with MS-related spasticity.³³ Multiple studies have tested MM and MM-related extracts for treating spasticity related to MS.^34,35 In a placebo-controlled crossover study, Corey-Bloom et al³⁴ reported a significant reduction in spasticity, measured using the modified Ashworth scale, in MS patients receiving Cannabis cigarettes vs placebo cigarettes (P < .0001). However, compared with the placebo group, patients who received MM had significant adverse effects, primarily cognitive impairment (P = .003).

In a multicenter RCT (N = 572 patients with refractory MS spasticity), Novotna et al³⁶ evaluated nabiximols, an oral mucosal spray of a formulated extract of Cannabis that contains THC and CBD in a 1:1 ratio. They assessed spasticity using the Numerical Spasticity Rating Scale (NRS). Results were confirmed by measuring the number of daily spasms, self-report of sleep quality, and activities of daily living. After 4 weeks of single-blind treatment, patients who responded to nabiximols (≥20% improvement in spasticity) were randomized to a placebo group or nabiximols group for 12 additional weeks. After 12 weeks, compared with those who received placebo, those in the nabiximols group experienced a statistically significant reduction in spasticity based on NRS score (P = .0002).
 

For a summary of evidence on MM for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis, see Box 3.^37-43

Box 3
Cannabis for treating glaucoma, Crohn’s disease, Parkinson’s disease, and amyotrophic lateral sclerosis

Psychiatric illnesses

Dementia-related behavioral disturbances. A few clinical trials with small sample sizes have found evidence supporting the use of MM compounds for alleviating neuropsychiatric symptoms of patients with dementia. An open-label pilot study of 6 individuals with late-stage dementia who received dronabinol, 2.5 mg/d, for 2 weeks, found a significant reduction (compared with baseline) in nighttime motor activity as measured with an actometer (P < .0028).⁴⁴ The secondary Neuropsychiatric Inventory (NPI) assessment found reductions in aberrant motor behavior (P = .042), agitation (P = .042), and nighttime behaviors (P = .42).

A 2014 retrospective analysis of 40 inpatients with dementia-related agitation and appetite loss who were treated with dronabinol (mean dosage: 7.03 mg/d) found reductions in all aspects of agitation, including aberrant vocalization, motor agitation, aggressiveness, and treatment resistance, as measured with the Pittsburgh Agitation Scale (P < .0001).⁴⁵ The study found no significant improvements in appetite, Global Assessment of Functioning mean score, or number of times patients awoke during the night. Adverse effects included sedation and delirium.

A RCT of 50 dementia patients with clinically relevant neuropsychiatric symptoms found no significant difference in mean NPI scores between patients given placebo and those who received nabiximols, 1.5 mg, 3 times daily.⁴⁶ There were no significant differences found in agitation, QOL, life activities, or caregiver-scored Caregiver Global Impression of Change scale.

In a small RCT, THC was safe and well tolerated in 10 older patients with dementia.⁴⁷ A 2009 Cochrane review⁴⁸ concluded that there was no evidence for the efficacy of MM in treating the neuropsychiatric symptoms related to dementia.

PTSD. Preclinical evidence shows that the endocannabinoid system is involved in regulating emotional memory. Evidence also suggests that cannabinoids may facilitate the extinction of aversive memories.^49,50

In 2009, New Mexico became the first state to authorize the use of MM for patients with PTSD. In a study of patients applying for the New Mexico Medical Cannabis Program, researchers used the Clinician Administered Posttraumatic Scale (CAPS) to assess PTSD symptoms.⁵¹ A retrospective chart review of the first 80 patients eval­uated found significant (P < .0001) reductions of several PTSD symptoms, including intrusive memories, distressing dreams, flashbacks, numbing and avoidance, and hyperarousal, in the group using MM vs those not using MM. There also was a significant difference in CAPS total score (P < .0001). Patients reported a 75% reduction in PTSD symptoms while using MM. This study has several limitations: It was a retrospective review, not an RCT, and patients were prescreened and knew before the study began that MM helped their PTSD symptoms.

In another retrospective study, researchers evaluated treatment with nabilone, 0.5 to 6 mg/d, in 104 incarcerated men with various major mental illnesses; most (91%) met criteria for Cannabis dependence.⁵² They found significant improvements in sleep and PTSD symptoms.

A double-blind RCT evaluated MM in 10 Canadian male soldiers with PTSD who experienced nightmares despite standard medication treatment. Adjunctive nabilone (maximum dose: 3 mg/d) resulted in a reduction in nightmares as measured by the CAPS recurrent distressing dream of the event item score.⁵³

Currently, there are no adequately powered RCTs of MM in a diverse group of PTSD patients. Most studies are open-label, enriched design, and included white male veterans. No well-conducted trials have evaluated patients with noncombat-related PTSD. Most of the relevant literature consists of case reports of Cannabis use by patients with PTSD.

Anxiety disorders.Patients frequently indicate that smoking Cannabis helps relieve their anxiety, although there is no replicated evidence based on double-blind RCTs to support this. However, in rat models CBD has been shown to facilitate extinction of conditioned fear via the endocannabinoid system.^54-56 The mechanism of action is not completely understood. CBD has been shown to have antagonistic action at CB₁ and CB₂ receptors. It may have similar effects on memory extinction and may be an adjunct to exposure therapies for anxiety disorders.

Das et al⁵⁷ studied the effects of CBD (32 mg) on extinction and consolidation of memory related to contextual fear in 48 individuals. They found that CBD can enhance extinction learning, and suggested it may have potential as an adjunct to extinction-based therapies for anxiety disorders.

Caveats: Adverse effects, lack of RCTs

Cannabis use causes impairment of learning, memory, attention, and working memory. Adolescents are particularly vulnerable to the effects of Cannabis on brain development at a time when synaptic pruning and increased myelination occur. Normal brain development could be disrupted. Some studies have linked Cannabis use to abnormalities in the amygdala, hippocampus, frontal lobe, and cerebellum. From 1995 to 2014, the potency of Cannabis (THC concentration) increased from 4% to 12%.⁵⁸ This has substantial implications for increased abuse among adolescents and the deleterious effects of Cannabis on the brain.

Heavy Cannabis use impairs motivation and could precipitate psychosis in vulnerable individuals. Cannabis use may be linked to the development of schizophrenia.⁵⁹

There are no well-conducted RCTs on the efficacy of MM, and adequate safety data are lacking. There is also lack of consensus among qualified experts. There is soft evidence that MM may be helpful in some medical conditions, including but not limited to CINV, neuropathic pain, epilepsy, and MS-related spasticity. Currently, the benefits of using MM do not appear to outweigh the risks.

Bottom Line

Limited evidence suggests medical marijuana (MM) may be beneficial for treating a few medical conditions, including neuropathic pain and chemotherapy-induced nausea and vomiting. There is no clear and convincing evidence MM is beneficial for psychiatric disorders, and Cannabis can impair cognition and attention and may precipitate psychosis. The risk of deleterious effects are greater in adolescents.

Related Resources

• Nguyen DH, Thant TM. Caring for medical marijuana patients who request controlled prescriptions. Current Psychiatry. 2017;16(8):50-51.
• National Institute on Drug Abuse. Marijuana as medicine. https://www.drugabuse.gov/publications/drugfacts/ marijuana-medicine.

Drug Brand Names

Alizapride • Litican, Superan
Chlorpromazine • Thorazine
Domperidone • Motilium
Dronabinol • Marinol, Syndros
Haloperidol • Haldol
Metoclopramide • Reglan
Nabilone • Cesamet
Nabiximols • Sativex
Ondansetron • Zofran, Zuplenz
Prochlorperazine • Compazine
Thiethylperazine • Torecan

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in the realm of behavioral health, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which behavioral health care can be objectively assessed and monitored, and payers such as the Centers for Medicare and Medicaid Services increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate mental health and primary care (among other practices) by establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks patient progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes are monitored by A1C lab tests.⁶ An extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a "lack of systematic measurement to determine whether patients are responding to treatment."⁸ That same brief points to the many validated, easy-to-administer rating scales and screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use to "treating high blood pressure without using a blood pressure cuff to measure if a patient's blood pressure is improving."⁸ In fact, it is estimated that only 18% of psychiatrists and 11% of psychologists use rating scales routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients; implementing these scales in primary care can help early detection of behavioral health problems.

Behavioral health is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

Let's review a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Solutions website (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

QUALITY CRITERIA FOR RATING SCALES

The quality of a rating scale is determined by the following attributes.

Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.

Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.

Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).

Establishment of norms. Whether a scale provides reference values for different clinical groups.

Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.¹²

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don't require much time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer- and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both can also help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

ENDORSED RATING SCALES

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a nine-item self-report questionnaire that can help to detect depression and supplement a thorough mental health interview. It scores the nine DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test-retest reliability in screening for depression, and normative data on the instrument's use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decreases, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥ 10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining two questions provide additional clinical information, addressing family history of manic-depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population, although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.^20,21 Nonetheless, its specificity of > 97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

The GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate seven items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age- and sex-specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely used screening tool that was originally developed to detect alcohol abuse but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains four simple questions, with 1 point assigned to each positive answer (see Table); the simple mnemonic makes the questions easy to ­remember and to administer in a clinical setting.

CAGE has demonstrated validity, with one study determining that scores ≥ 2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is two pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased in an interview format, and while clinicians are encouraged to receive training prior to its administration, specific training in mental health is not required.

The "Lifetime/Recent" version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the "Since Last Visit" version of the scale assesses suicidality in patients who have completed at least one Lifetime/Recent C-SSRS assessment. A truncated, six-item "Screener" version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is eight to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate by 65% in one of the largest providers of community-based behavioral health care in the United States.³²

USING SCALES TO AUGMENT CARE

Each of the scales described in this article can easily be incorporated into clinical practice. The information the scales provide can be used to track progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician's assessment and follow-up interviews.⁵

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in the realm of behavioral health, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which behavioral health care can be objectively assessed and monitored, and payers such as the Centers for Medicare and Medicaid Services increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate mental health and primary care (among other practices) by establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks patient progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes are monitored by A1C lab tests.⁶ An extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a "lack of systematic measurement to determine whether patients are responding to treatment."⁸ That same brief points to the many validated, easy-to-administer rating scales and screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use to "treating high blood pressure without using a blood pressure cuff to measure if a patient's blood pressure is improving."⁸ In fact, it is estimated that only 18% of psychiatrists and 11% of psychologists use rating scales routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients; implementing these scales in primary care can help early detection of behavioral health problems.

Behavioral health is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

Let's review a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Solutions website (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

QUALITY CRITERIA FOR RATING SCALES

The quality of a rating scale is determined by the following attributes.

Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.

Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.

Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).

Establishment of norms. Whether a scale provides reference values for different clinical groups.

Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.¹²

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don't require much time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer- and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both can also help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

ENDORSED RATING SCALES

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a nine-item self-report questionnaire that can help to detect depression and supplement a thorough mental health interview. It scores the nine DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test-retest reliability in screening for depression, and normative data on the instrument's use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decreases, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥ 10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining two questions provide additional clinical information, addressing family history of manic-depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population, although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.^20,21 Nonetheless, its specificity of > 97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

The GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate seven items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age- and sex-specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely used screening tool that was originally developed to detect alcohol abuse but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains four simple questions, with 1 point assigned to each positive answer (see Table); the simple mnemonic makes the questions easy to ­remember and to administer in a clinical setting.

CAGE has demonstrated validity, with one study determining that scores ≥ 2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is two pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased in an interview format, and while clinicians are encouraged to receive training prior to its administration, specific training in mental health is not required.

The "Lifetime/Recent" version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the "Since Last Visit" version of the scale assesses suicidality in patients who have completed at least one Lifetime/Recent C-SSRS assessment. A truncated, six-item "Screener" version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is eight to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate by 65% in one of the largest providers of community-based behavioral health care in the United States.³²

USING SCALES TO AUGMENT CARE

Each of the scales described in this article can easily be incorporated into clinical practice. The information the scales provide can be used to track progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician's assessment and follow-up interviews.⁵

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in the realm of behavioral health, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which behavioral health care can be objectively assessed and monitored, and payers such as the Centers for Medicare and Medicaid Services increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate mental health and primary care (among other practices) by establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks patient progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes are monitored by A1C lab tests.⁶ An extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a "lack of systematic measurement to determine whether patients are responding to treatment."⁸ That same brief points to the many validated, easy-to-administer rating scales and screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use to "treating high blood pressure without using a blood pressure cuff to measure if a patient's blood pressure is improving."⁸ In fact, it is estimated that only 18% of psychiatrists and 11% of psychologists use rating scales routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients; implementing these scales in primary care can help early detection of behavioral health problems.

Behavioral health is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

Let's review a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Solutions website (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

QUALITY CRITERIA FOR RATING SCALES

The quality of a rating scale is determined by the following attributes.

Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.

Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.

Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).

Establishment of norms. Whether a scale provides reference values for different clinical groups.

Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.¹²

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don't require much time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer- and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both can also help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

ENDORSED RATING SCALES

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a nine-item self-report questionnaire that can help to detect depression and supplement a thorough mental health interview. It scores the nine DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test-retest reliability in screening for depression, and normative data on the instrument's use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decreases, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥ 10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining two questions provide additional clinical information, addressing family history of manic-depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population, although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.^20,21 Nonetheless, its specificity of > 97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

The GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate seven items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age- and sex-specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely used screening tool that was originally developed to detect alcohol abuse but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains four simple questions, with 1 point assigned to each positive answer (see Table); the simple mnemonic makes the questions easy to ­remember and to administer in a clinical setting.

CAGE has demonstrated validity, with one study determining that scores ≥ 2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is two pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased in an interview format, and while clinicians are encouraged to receive training prior to its administration, specific training in mental health is not required.

The "Lifetime/Recent" version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the "Since Last Visit" version of the scale assesses suicidality in patients who have completed at least one Lifetime/Recent C-SSRS assessment. A truncated, six-item "Screener" version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is eight to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate by 65% in one of the largest providers of community-based behavioral health care in the United States.³²

USING SCALES TO AUGMENT CARE

Each of the scales described in this article can easily be incorporated into clinical practice. The information the scales provide can be used to track progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician's assessment and follow-up interviews.⁵

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in psychiatry, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which psychiatric care can be objectively assessed and monitored, and payers such as Centers for Medicare and Medicaid Services (CMS) increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate psychiatric and primary care by (among other practices) establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks a patient’s progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes mellitus are monitored by hemoglobin A_1c laboratory tests.⁶ An increasingly extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane Review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a “lack of systematic measurement to determine whether patients are responding to treatment.”⁸ That same brief points to the many easy-to-administer and validated rating scales and other screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use as “equivalent to treating high blood pressure without using a blood pressure cuff to measure if a patient’s blood pressure is improving.”⁸ It is estimated that only 18% of psychiatrists and 11% of psychologists administer them routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients.
 

Psychiatry is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

This article reviews a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Systems Web site (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

Quality criteria for rating scales

The quality of a rating scale is determined by the following attributes¹²:

• Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.
• Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.
• Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).
• Establishment of norms. Whether a scale provides reference values for different clinical groups.
• Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don’t require clinician or staff time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients either may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both also can help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a 9-item self-report questionnaire that can help to detect the presence of depression and supplement a thorough psychiatric and mental health interview. It scores the 9 DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test–retest reliability in screening for depression, and normative data on the instrument’s use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decrease, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining 2 questions provide additional, clinical information, because they address family history of manic–depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population,²⁰ although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.²¹ Nonetheless, its specificity of >97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate 7 items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age and sex specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely-used screening tool that was originally developed to detect alcohol abuse, but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains 4 simple questions, with 1 point is assigned to each positive answer.

Have you ever:
1. Felt the need to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

The simple mnemonic CAGE makes the questions easy to remember and to administer in a clinical setting. CAGE has demonstrated validity, with one study determining that CAGE scores ≥2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is 2 pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased for use in an interview format, and clinicians are encouraged to receive training prior to its administration, although specific training in mental health is not required.

The “Lifetime/Recent” version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the “Since Last Visit” version of the scale assesses suicidality in patients who have completed at least 1 Lifetime/Recent C-SSRS assessment. A truncated, 6-item “Screener” version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is 8 to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate 65% in one of the largest providers of community-based behavioral health care in the United States.³²

Using scales to augment care

Each of the scales described in this article can easily be incorporated into clinical practice and offers psychiatrists important clinical information that may have been missed or not addressed in the initial clinical interview. This information can be used to follow progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician’s assessment and follow-up interviews.⁵
 

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in psychiatry, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which psychiatric care can be objectively assessed and monitored, and payers such as Centers for Medicare and Medicaid Services (CMS) increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate psychiatric and primary care by (among other practices) establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks a patient’s progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes mellitus are monitored by hemoglobin A_1c laboratory tests.⁶ An increasingly extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane Review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a “lack of systematic measurement to determine whether patients are responding to treatment.”⁸ That same brief points to the many easy-to-administer and validated rating scales and other screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use as “equivalent to treating high blood pressure without using a blood pressure cuff to measure if a patient’s blood pressure is improving.”⁸ It is estimated that only 18% of psychiatrists and 11% of psychologists administer them routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients.
 

Psychiatry is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

This article reviews a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Systems Web site (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

Quality criteria for rating scales

The quality of a rating scale is determined by the following attributes¹²:

• Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.
• Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.
• Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).
• Establishment of norms. Whether a scale provides reference values for different clinical groups.
• Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don’t require clinician or staff time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients either may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both also can help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a 9-item self-report questionnaire that can help to detect the presence of depression and supplement a thorough psychiatric and mental health interview. It scores the 9 DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test–retest reliability in screening for depression, and normative data on the instrument’s use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decrease, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining 2 questions provide additional, clinical information, because they address family history of manic–depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population,²⁰ although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.²¹ Nonetheless, its specificity of >97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate 7 items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age and sex specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely-used screening tool that was originally developed to detect alcohol abuse, but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains 4 simple questions, with 1 point is assigned to each positive answer.

Have you ever:
1. Felt the need to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

The simple mnemonic CAGE makes the questions easy to remember and to administer in a clinical setting. CAGE has demonstrated validity, with one study determining that CAGE scores ≥2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is 2 pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased for use in an interview format, and clinicians are encouraged to receive training prior to its administration, although specific training in mental health is not required.

The “Lifetime/Recent” version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the “Since Last Visit” version of the scale assesses suicidality in patients who have completed at least 1 Lifetime/Recent C-SSRS assessment. A truncated, 6-item “Screener” version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is 8 to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate 65% in one of the largest providers of community-based behavioral health care in the United States.³²

Using scales to augment care

Each of the scales described in this article can easily be incorporated into clinical practice and offers psychiatrists important clinical information that may have been missed or not addressed in the initial clinical interview. This information can be used to follow progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician’s assessment and follow-up interviews.⁵
 

In the current health care environment, there is an increasing demand for objective assessment of disease states.¹ This is particularly apparent in psychiatry, where documentation of outcomes lags that of other areas of medicine.

In 2012, the additional health care costs incurred by persons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diagnoses.² Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways in which psychiatric care can be objectively assessed and monitored, and payers such as Centers for Medicare and Medicaid Services (CMS) increasingly require objective documentation of disease state improvement for payment.³

Support for objective assessment of disease derives from the collaborative care model. This model is designed to better integrate psychiatric and primary care by (among other practices) establishing the Patient-Centered Medical Home and emphasizing screening and monitoring patient-reported outcomes over time to assess treatment response.⁴ This approach, which is endorsed by the American Psychiatric Association, is associated with significant improvements in outcomes compared with usual care.⁵ It tracks a patient’s progress using validated clinical rating scales and other screening tools (eg, Patient Health Questionnaire [PHQ-9] for depression), an approach that is analogous to how patients with type 2 diabetes mellitus are monitored by hemoglobin A_1c laboratory tests.⁶ An increasingly extensive body of research supports the impact of this approach on treatment. A 2012 Cochrane Review associated collaborative care with significant improvements in depression and anxiety outcomes compared with usual treatment.⁷

Despite these findings, a recent Kennedy Forum brief asserts that behavioral health is characterized by a “lack of systematic measurement to determine whether patients are responding to treatment.”⁸ That same brief points to the many easy-to-administer and validated rating scales and other screening tools that can reliably measure the frequency and severity of psychiatric symptoms over time, and likens the lack of their use as “equivalent to treating high blood pressure without using a blood pressure cuff to measure if a patient’s blood pressure is improving.”⁸ It is estimated that only 18% of psychiatrists and 11% of psychologists administer them routinely.^9,10 This lack of use denies clinicians important information that can help detect deterioration or lack of improvement in their patients.
 

Psychiatry is replete with rating scales and screening tools, and the number of competing scales can make choosing a measure difficult.¹ Nonetheless, not all scales are appropriate for clinical use; many are designed for research, for instance, and are lengthy and difficult to administer.

This article reviews a number of rating scales that are brief, useful, and easy to administer. A framework for the screening tools addressed in this article is available on the federally funded Center for Integrated Health Systems Web site (www.integration.samhsa.gov). This site promotes the use of tools designed to assist in screening and monitoring for depression, anxiety, bipolar disorder, substance use, and suicidality.¹¹

Quality criteria for rating scales

The quality of a rating scale is determined by the following attributes¹²:

• Objectivity. The ability of a scale to obtain the same results, regardless of who administers, analyzes, or interprets it.
• Reliability. The ability of a scale to convey consistent and reproducible information across time, patients, and raters.
• Validity. The degree to which the scale measures what it is supposed to measure (eg, depressive symptoms). Sensitivity and specificity are measures of validity and provide additional information about the rating scale; namely, whether the scale can detect the presence of a disease (sensitivity) and whether it detects only that disease or condition and not another (specificity).
• Establishment of norms. Whether a scale provides reference values for different clinical groups.
• Practicability. The resources required to administer the assessment instrument in terms of time, staff, and material.

In addition to meeting these quality criteria, selection of a scale can be based on whether it is self-rated or observer-rated. Advantages to self-rated scales, such as the PHQ-9, Mood Disorder Questionnaire (MDQ), and Generalized Anxiety Disorder 7-item (GAD-7) scale, are their practicability—they are easy to administer and don’t require clinician or staff time—and their use in evaluating and raising awareness of subjective states.

However, reliability may be a concern, as some patients either may lack insight or exaggerate or mask symptoms when completing such scales.¹³ Both observer and self-rated scales can be used together to minimize bias, identify symptoms that might have been missed/not addressed in the clinical interview, and drive clinical decision-making. Both also can help patients communicate with their providers and make them feel more involved in clinical decision-making.⁸

The following scales have met many of the quality criteria described here and are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide useful clinical information that can assist in diagnosis and monitoring patient outcomes.

Patient Health Questionnaire

PHQ-9 is a 9-item self-report questionnaire that can help to detect the presence of depression and supplement a thorough psychiatric and mental health interview. It scores the 9 DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every day). It is a public resource that is easy to find online, available without cost in several languages, and takes just a few minutes to complete.¹⁴

PHQ-9 has shown excellent test–retest reliability in screening for depression, and normative data on the instrument’s use are available in various clinical populations.¹⁵ Research has shown that as PHQ-9 depression scores increase, functional status decrease, while depressive symptoms, sick days, and health care utilization increase.¹⁵ In one study, a PHQ-9 score of ≥10 had 88% sensitivity and specificity for detecting depression, with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression, respectively.¹⁶ In addition to its use as a screening tool, PHQ-9 is a responsive and reliable measure of depression treatment outcomes.¹⁷

Mood Disorder Questionnaire

MDQ is another brief, self-report questionnaire that is available online. It is designed to identify and monitor patients who are likely to meet diagnostic criteria for bipolar disorder.^18,19

The first question on the MDQ asks if the patient has experienced any of 13 common mood and behavior symptoms. The second question asks if these symptoms have ever occurred at the same time, and the third asks the degree to which the patient finds the symptoms to be problematic. The remaining 2 questions provide additional, clinical information, because they address family history of manic–depressive illness or bipolar disorder and whether a diagnosis of either disorder has been made.

The MDQ has shown validity in assessing bipolar disorder symptoms in a general population,²⁰ although recent research suggests that imprecise recall bias may limit its reliability in detecting hypomanic episodes earlier in life.²¹ Nonetheless, its specificity of >97% means that it will effectively screen out just about all true negatives.¹⁸

Generalized Anxiety Disorder 7-item scale

GAD-7 scale is a brief, self-administered questionnaire for screening and measuring severity of GAD.²² It asks patients to rate 7 items that represent problems with general anxiety and scores each item on a scale of 0 (not at all) to 3 (nearly every day). Similar to the other measures, it is easily accessible online.

Research evidence supports the reliability and validity of GAD-7 as a measure of anxiety in the general population. Sensitivity and specificity are 89% and 82%, respectively. Normative data for age and sex specific subgroups support its use across age groups and in both males and females.²³ The GAD-7 performs well for detecting and monitoring not only GAD but also panic disorder, social anxiety disorder, and posttraumatic stress disorder.²⁴

CAGE questionnaire for detection of substance use

The CAGE questionnaire is a widely-used screening tool that was originally developed to detect alcohol abuse, but has been adapted to assess other substance abuse.^25,26 The omission of substance abuse from diagnostic consideration can have a major effect on quality of care, because substance abuse can be the underlying cause of other diseases. Therefore, routine administration of this instrument in clinical practice can lead to better understanding and monitoring of patient health.²⁷

Similar to other instruments, CAGE is free and available online.²⁷ It contains 4 simple questions, with 1 point is assigned to each positive answer.

Have you ever:
1. Felt the need to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

The simple mnemonic CAGE makes the questions easy to remember and to administer in a clinical setting. CAGE has demonstrated validity, with one study determining that CAGE scores ≥2 had a specificity and sensitivity of 76% and 93%, respectively, for identifying excessive drinking, and a specificity and sensitivity of 77% and 91%, respectively, for identifying alcohol abuse.²⁸

Columbia Suicide Severity Rating Scale (C-SSRS)

C-SSRS was developed by researchers at Columbia University to assess the severity of and track changes over time in suicidal ideation and behavior. C-SSRS is 2 pages and takes only a few minutes to administer; however, it also may be completed as a self-report measure. The questions are phrased for use in an interview format, and clinicians are encouraged to receive training prior to its administration, although specific training in mental health is not required.

The “Lifetime/Recent” version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior, whereas the “Since Last Visit” version of the scale assesses suicidality in patients who have completed at least 1 Lifetime/Recent C-SSRS assessment. A truncated, 6-item “Screener” version is typically used in emergency situations. A risk assessment can be added to either the Full or Screener version to summarize the answers from C-SSRS and document risk and protective factors.²⁹

Several studies have found C-SSRS to be reliable and valid for identifying suicide risk in children and adults.^30,31USA Today reported that an individual exhibiting even a single behavior identified by the scale is 8 to 10 times more likely to complete suicide.³² In addition, the C-SSRS has helped reduce the suicide rate 65% in one of the largest providers of community-based behavioral health care in the United States.³²

Using scales to augment care

Each of the scales described in this article can easily be incorporated into clinical practice and offers psychiatrists important clinical information that may have been missed or not addressed in the initial clinical interview. This information can be used to follow progression of symptoms and effectiveness of treatment. Although rating scales should never be used alone to establish a diagnosis or clinical treatment plan, they can and should be used to augment information from the clinician’s assessment and follow-up interviews.⁵
 

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.