Current Psychiatry

Mr. S, age 77, is admitted to a long-term care facility due to progressive cognitive impairment and sexually inappropriate behavior. He has a history of sexual assault of medical staff. His medical history includes significant frontotemporal dementia (FTD) with behavioral disturbances, abnormal sexual behaviors, subclinical hypothyroidism, schizoid personality disorder, Parkinson disease, posttraumatic stress disorder, and hyperammonemia.

Upon admission, Mr. S’s vital signs are within normal limits except for an elevated thyroid-stimulating hormone (4.54 mIU/L; reference range 0.40 to 4.50 mIU/L). Prior cognitive testing results and updated ammonia levels are unavailable. Mr. S’s current medications include acetaminophen 650 mg every 4 hours as needed for pain, calcium carbonate/vitamin D twice daily for bone health, carbidopa/levodopa 25/100 mg twice daily for Parkinson disease, melatonin 3 mg/d at bedtime for insomnia, quetiapine 25 mg twice daily for psychosis with disturbance of behavior and 12.5 mg every 4 hours as needed for agitation, and trazodone 50 mg/d at bedtime for insomnia. Before Mr. S was admitted, previous therapy with selective serotonin reuptake inhibitors (SSRIs) had been tapered and discontinued. Mr. S had also started antipsychotic therapy at another facility due to worsening behaviors.

In patients with dementia, the brain is experiencing neurodegeneration. Progressively, neurons may stop functioning, lose connections with other neurons, and ultimately face cell death. The specific dementia diagnosis and its clinical features depend on the type of neurons and region of the brain affected.^1,2

FTD occurs in response to damage to the frontal and temporal lobes. The frontal lobe correlates to executive functioning, while the temporal lobe plays a role in speech and comprehension. Damage to these areas may result in loss of movement, trouble speaking, difficulty solving complex problems, and problems with social behavior. Specifically, damage to the orbital frontal cortex may cause disinhibition and abnormal behaviors, including emotional lability, vulgarity, and indifference to social nuances.¹ Within an FTD diagnosis, there are 3 disorders: behavioral-variant FTD (bvFTD), semantic dementia, and progressive nonfluent aphasia.¹ Specifically, bvFTD can result in abnormal sexual behaviors such as making sexually inappropriate statements, masturbating in public, undressing in public, inappropriately or aggressively touching others, or confusing another individual as an intimate partner. In addition to cognitive impairment, these neurobehavioral symptoms can significantly impact an individual’s quality of life while increasing caregiver burden.²

Occurring at a similar frequency to Alzheimer’s disease in patients age <65, FTD is one of the more common causes of early-onset dementia. The mean age of onset is 58 and onset after age 75 is particularly unusual. Memory may not be affected early in the course of the disease, but social changes are likely. As FTD progresses, symptoms will resemble those of Alzheimer’s disease and patients will require assistance with activities of daily living. In later stages of FTD, patients will exhibit language and behavior symptoms. Due to its unique progression, FTD can be commonly misdiagnosed as other mental illnesses or neurocognitive disorders.¹

Approaches to treatment: What to consider

Both nonpharmacologic and pharmacologic interventions are appropriate for addressing FTD. Because nonpharmacologic options improve patient safety and overall physical health, they should be used whenever practical. These interventions include safe driving measures, exercise, speech therapy, redirection, offering simple choices when making decisions, and managing environmental cues for behaviors that should be encouraged or discouraged.³

There are no FDA-approved medications to cure or slow the progression of FTD. Therefore, treatment is focused on alleviating neurobehavioral symptoms. The symptoms depend on the type of FTD the patient has; they include cognitive impairment, anxiety, insomnia or sleep disturbances, compulsive behaviors, speech and language problems, and agitation. While many medications have been commonly used for symptomatic relief, evidence for the efficacy of these treatments in FTD is limited.²

Continue to: A review of the literature...

A review of the literature on potential treatments for cognitive impairment and behavioral symptoms of FTD identified 2 trials and 1 case series (Table 1^4-6) in addition to a 2014 review article⁷ of current pharmacologic treatments. These trials evaluated cognitive improvement with rivastigmine, memantine, galantamine, and donepezil. None of the trials found a significant benefit from any of these medications for cognitive improvement in FTD. Data were conflicting on whether these medications improved or worsened behavioral symptoms. For example, the case series of 3 patients by Swanberg⁶ suggested improvement in behavior with memantine, while an open-label study analyzed in a 2014 review article⁷ found that donepezil may have worsened behaviors. Use of cholinesterase inhibitors or memantine in FTD is not recommended unless it is not certain if the patient has FTD or Alzheimer’s disease.⁷

Addressing sexual behaviors. Creating a treatment regimen for FTD behavioral symptoms—specifically for abnormal sexual behaviors—can be challenging. Before starting pharmacotherapy directed at behavioral symptoms secondary to FTD, other causes of symptoms such as delirium, pain, or discomfort should be excluded. Nonpharmacologic approaches should be aimed at the type of sexual behavior and likely underlying environmental cause. For example, patients may inappropriately disrobe themselves. To address this behavior, hospital staff or caregivers should first eliminate environmental causes by ensuring the room is at a comfortable temperature, dressing the patient in light, breathable clothing, or checking if the patient needs to use the bathroom. If no environmental causes are found, a one-piece jumpsuit with closures on the back of the garment could be utilized to increase the difficulty of undressing.

Other nonpharmacologic methods include providing private areas for patients who are behaving inappropriately or removing potentially stimulating television or media from the environment. Another option is to increase the use of positive, pleasant stimuli. One approach that has shown benefit is music therapy, utilizing popular music genres from the patient’s youth.³

Evidence for pharmacotherapy is limited and largely from case reports and case series. A 2020 meta-analysis by Trieu et al⁸ reviewed 23 studies to expand on current clinical guidance for patients with bvFTD. These studies showed improvements in behavioral symptoms and reductions in caregiver fatigue with citalopram, trazodone, paroxetine, and fluvoxamine. Six of the trials included in this meta-analysis that evaluated these 4 medications are summarized in Table 2.^9-14 

Due to the lower risk of adverse effects and favorable safety profiles, SSRIs and trazodone are considered first-line treatment options. Benefit from these medications is theorized to be a result of their serotonergic effects, because serotonin abnormalities and dysfunction have been linked to FTD symptoms. For example, in a patient experiencing hypersexuality, the common adverse effect of low libido associated with SSRIs can be particularly beneficial.⁸

Continue to: Other medication classes studied in patients...

Other medication classes studied in patients with FTD include antipsychotics, stimulants, anticonvulsants, benzo­diazepines, and hormonal therapies. In addition to a black box warning for increased mortality in older patients with dementia-related psychosis, antipsychotics are associated with other serious adverse effects and should be used with caution.⁷

FTD is a debilitating disease that has a major impact on quality of life, particularly when behavioral symptoms accompany cognitive decline. Though some therapies may possibly improve behavioral symptoms, their routine use remains controversial due to a lack of clear evidence of benefit. In caring for patients with FTD and behavioral symptoms, a multimodal, team-based approach is vital.¹

CASE CONTINUED

The treatment team starts Mr. S on several of the modalities discussed in this article over the span of 2 years, with limited efficacy. Nonpharmacologic methods do not provide much benefit because Mr. S is extremely difficult to redirect. Given Mr. S’s past trials of SSRIs prior to admission, sertraline was retrialed and titrated over 2 years. The highest dose utilized during his admission was 200 mg/d. The team starts estrogen therapy but tapers and discontinues it due to ineffectiveness. Mr. S’s use of carbidopa/levodopa is thought to be contributing to his behavioral abnormalities, so the team tapers it to discontinuation; however, Mr. S’s sexually inappropriate behaviors and agitation continue. The team initiates a plan to reduce the dose of quetiapine and switch to gabapentin, but Mr. S fails gradual dose reduction due to his worsening behaviors. He starts gabapentin. The team gradually increases the dose of gabapentin to decrease libido and agitation, respectively. The increase in sertraline dose and use of nonpharmacologic modalities causes Mr. S’s use of as-needed antipsychotics to decrease.

Related Resources

• Ellison JM. What are the stages of frontotemporal dementia? BrightFocus Foundation. July 5, 2021. Accessed July 7, 2023. https://www.brightfocus.org/alzheimers/article/what-are-stages-frontotemporal-dementia
• Dementia and sexually inappropriate behavior. ReaDementia. January 31, 2022. Accessed July 7, 2023. https://readementia.com/dementia-and-sexually-inappropriate-behavior/

Drug Brand Names

Carbidopa/levodopa • Sinemet
Citalopram • Celexa
Donepezil • Aricept
Fluvoxamine • Luvox
Gabapentin • Neurontin
Galantamine • Razadyne
Memantine • Namenda
Paroxetine • Paxil
Quetiapine • Seroquel
Rivastigmine • Exelon
Sertraline • Zoloft
Trazodone • Desyrel

Mr. S, age 77, is admitted to a long-term care facility due to progressive cognitive impairment and sexually inappropriate behavior. He has a history of sexual assault of medical staff. His medical history includes significant frontotemporal dementia (FTD) with behavioral disturbances, abnormal sexual behaviors, subclinical hypothyroidism, schizoid personality disorder, Parkinson disease, posttraumatic stress disorder, and hyperammonemia.

Upon admission, Mr. S’s vital signs are within normal limits except for an elevated thyroid-stimulating hormone (4.54 mIU/L; reference range 0.40 to 4.50 mIU/L). Prior cognitive testing results and updated ammonia levels are unavailable. Mr. S’s current medications include acetaminophen 650 mg every 4 hours as needed for pain, calcium carbonate/vitamin D twice daily for bone health, carbidopa/levodopa 25/100 mg twice daily for Parkinson disease, melatonin 3 mg/d at bedtime for insomnia, quetiapine 25 mg twice daily for psychosis with disturbance of behavior and 12.5 mg every 4 hours as needed for agitation, and trazodone 50 mg/d at bedtime for insomnia. Before Mr. S was admitted, previous therapy with selective serotonin reuptake inhibitors (SSRIs) had been tapered and discontinued. Mr. S had also started antipsychotic therapy at another facility due to worsening behaviors.

In patients with dementia, the brain is experiencing neurodegeneration. Progressively, neurons may stop functioning, lose connections with other neurons, and ultimately face cell death. The specific dementia diagnosis and its clinical features depend on the type of neurons and region of the brain affected.^1,2

FTD occurs in response to damage to the frontal and temporal lobes. The frontal lobe correlates to executive functioning, while the temporal lobe plays a role in speech and comprehension. Damage to these areas may result in loss of movement, trouble speaking, difficulty solving complex problems, and problems with social behavior. Specifically, damage to the orbital frontal cortex may cause disinhibition and abnormal behaviors, including emotional lability, vulgarity, and indifference to social nuances.¹ Within an FTD diagnosis, there are 3 disorders: behavioral-variant FTD (bvFTD), semantic dementia, and progressive nonfluent aphasia.¹ Specifically, bvFTD can result in abnormal sexual behaviors such as making sexually inappropriate statements, masturbating in public, undressing in public, inappropriately or aggressively touching others, or confusing another individual as an intimate partner. In addition to cognitive impairment, these neurobehavioral symptoms can significantly impact an individual’s quality of life while increasing caregiver burden.²

Occurring at a similar frequency to Alzheimer’s disease in patients age <65, FTD is one of the more common causes of early-onset dementia. The mean age of onset is 58 and onset after age 75 is particularly unusual. Memory may not be affected early in the course of the disease, but social changes are likely. As FTD progresses, symptoms will resemble those of Alzheimer’s disease and patients will require assistance with activities of daily living. In later stages of FTD, patients will exhibit language and behavior symptoms. Due to its unique progression, FTD can be commonly misdiagnosed as other mental illnesses or neurocognitive disorders.¹

Approaches to treatment: What to consider

Both nonpharmacologic and pharmacologic interventions are appropriate for addressing FTD. Because nonpharmacologic options improve patient safety and overall physical health, they should be used whenever practical. These interventions include safe driving measures, exercise, speech therapy, redirection, offering simple choices when making decisions, and managing environmental cues for behaviors that should be encouraged or discouraged.³

There are no FDA-approved medications to cure or slow the progression of FTD. Therefore, treatment is focused on alleviating neurobehavioral symptoms. The symptoms depend on the type of FTD the patient has; they include cognitive impairment, anxiety, insomnia or sleep disturbances, compulsive behaviors, speech and language problems, and agitation. While many medications have been commonly used for symptomatic relief, evidence for the efficacy of these treatments in FTD is limited.²

Continue to: A review of the literature...

A review of the literature on potential treatments for cognitive impairment and behavioral symptoms of FTD identified 2 trials and 1 case series (Table 1^4-6) in addition to a 2014 review article⁷ of current pharmacologic treatments. These trials evaluated cognitive improvement with rivastigmine, memantine, galantamine, and donepezil. None of the trials found a significant benefit from any of these medications for cognitive improvement in FTD. Data were conflicting on whether these medications improved or worsened behavioral symptoms. For example, the case series of 3 patients by Swanberg⁶ suggested improvement in behavior with memantine, while an open-label study analyzed in a 2014 review article⁷ found that donepezil may have worsened behaviors. Use of cholinesterase inhibitors or memantine in FTD is not recommended unless it is not certain if the patient has FTD or Alzheimer’s disease.⁷

Addressing sexual behaviors. Creating a treatment regimen for FTD behavioral symptoms—specifically for abnormal sexual behaviors—can be challenging. Before starting pharmacotherapy directed at behavioral symptoms secondary to FTD, other causes of symptoms such as delirium, pain, or discomfort should be excluded. Nonpharmacologic approaches should be aimed at the type of sexual behavior and likely underlying environmental cause. For example, patients may inappropriately disrobe themselves. To address this behavior, hospital staff or caregivers should first eliminate environmental causes by ensuring the room is at a comfortable temperature, dressing the patient in light, breathable clothing, or checking if the patient needs to use the bathroom. If no environmental causes are found, a one-piece jumpsuit with closures on the back of the garment could be utilized to increase the difficulty of undressing.

Other nonpharmacologic methods include providing private areas for patients who are behaving inappropriately or removing potentially stimulating television or media from the environment. Another option is to increase the use of positive, pleasant stimuli. One approach that has shown benefit is music therapy, utilizing popular music genres from the patient’s youth.³

Evidence for pharmacotherapy is limited and largely from case reports and case series. A 2020 meta-analysis by Trieu et al⁸ reviewed 23 studies to expand on current clinical guidance for patients with bvFTD. These studies showed improvements in behavioral symptoms and reductions in caregiver fatigue with citalopram, trazodone, paroxetine, and fluvoxamine. Six of the trials included in this meta-analysis that evaluated these 4 medications are summarized in Table 2.^9-14 

Due to the lower risk of adverse effects and favorable safety profiles, SSRIs and trazodone are considered first-line treatment options. Benefit from these medications is theorized to be a result of their serotonergic effects, because serotonin abnormalities and dysfunction have been linked to FTD symptoms. For example, in a patient experiencing hypersexuality, the common adverse effect of low libido associated with SSRIs can be particularly beneficial.⁸

Continue to: Other medication classes studied in patients...

Other medication classes studied in patients with FTD include antipsychotics, stimulants, anticonvulsants, benzo­diazepines, and hormonal therapies. In addition to a black box warning for increased mortality in older patients with dementia-related psychosis, antipsychotics are associated with other serious adverse effects and should be used with caution.⁷

FTD is a debilitating disease that has a major impact on quality of life, particularly when behavioral symptoms accompany cognitive decline. Though some therapies may possibly improve behavioral symptoms, their routine use remains controversial due to a lack of clear evidence of benefit. In caring for patients with FTD and behavioral symptoms, a multimodal, team-based approach is vital.¹

CASE CONTINUED

The treatment team starts Mr. S on several of the modalities discussed in this article over the span of 2 years, with limited efficacy. Nonpharmacologic methods do not provide much benefit because Mr. S is extremely difficult to redirect. Given Mr. S’s past trials of SSRIs prior to admission, sertraline was retrialed and titrated over 2 years. The highest dose utilized during his admission was 200 mg/d. The team starts estrogen therapy but tapers and discontinues it due to ineffectiveness. Mr. S’s use of carbidopa/levodopa is thought to be contributing to his behavioral abnormalities, so the team tapers it to discontinuation; however, Mr. S’s sexually inappropriate behaviors and agitation continue. The team initiates a plan to reduce the dose of quetiapine and switch to gabapentin, but Mr. S fails gradual dose reduction due to his worsening behaviors. He starts gabapentin. The team gradually increases the dose of gabapentin to decrease libido and agitation, respectively. The increase in sertraline dose and use of nonpharmacologic modalities causes Mr. S’s use of as-needed antipsychotics to decrease.

Related Resources

• Ellison JM. What are the stages of frontotemporal dementia? BrightFocus Foundation. July 5, 2021. Accessed July 7, 2023. https://www.brightfocus.org/alzheimers/article/what-are-stages-frontotemporal-dementia
• Dementia and sexually inappropriate behavior. ReaDementia. January 31, 2022. Accessed July 7, 2023. https://readementia.com/dementia-and-sexually-inappropriate-behavior/

Drug Brand Names

Carbidopa/levodopa • Sinemet
Citalopram • Celexa
Donepezil • Aricept
Fluvoxamine • Luvox
Gabapentin • Neurontin
Galantamine • Razadyne
Memantine • Namenda
Paroxetine • Paxil
Quetiapine • Seroquel
Rivastigmine • Exelon
Sertraline • Zoloft
Trazodone • Desyrel

Mr. S, age 77, is admitted to a long-term care facility due to progressive cognitive impairment and sexually inappropriate behavior. He has a history of sexual assault of medical staff. His medical history includes significant frontotemporal dementia (FTD) with behavioral disturbances, abnormal sexual behaviors, subclinical hypothyroidism, schizoid personality disorder, Parkinson disease, posttraumatic stress disorder, and hyperammonemia.

Upon admission, Mr. S’s vital signs are within normal limits except for an elevated thyroid-stimulating hormone (4.54 mIU/L; reference range 0.40 to 4.50 mIU/L). Prior cognitive testing results and updated ammonia levels are unavailable. Mr. S’s current medications include acetaminophen 650 mg every 4 hours as needed for pain, calcium carbonate/vitamin D twice daily for bone health, carbidopa/levodopa 25/100 mg twice daily for Parkinson disease, melatonin 3 mg/d at bedtime for insomnia, quetiapine 25 mg twice daily for psychosis with disturbance of behavior and 12.5 mg every 4 hours as needed for agitation, and trazodone 50 mg/d at bedtime for insomnia. Before Mr. S was admitted, previous therapy with selective serotonin reuptake inhibitors (SSRIs) had been tapered and discontinued. Mr. S had also started antipsychotic therapy at another facility due to worsening behaviors.

In patients with dementia, the brain is experiencing neurodegeneration. Progressively, neurons may stop functioning, lose connections with other neurons, and ultimately face cell death. The specific dementia diagnosis and its clinical features depend on the type of neurons and region of the brain affected.^1,2

FTD occurs in response to damage to the frontal and temporal lobes. The frontal lobe correlates to executive functioning, while the temporal lobe plays a role in speech and comprehension. Damage to these areas may result in loss of movement, trouble speaking, difficulty solving complex problems, and problems with social behavior. Specifically, damage to the orbital frontal cortex may cause disinhibition and abnormal behaviors, including emotional lability, vulgarity, and indifference to social nuances.¹ Within an FTD diagnosis, there are 3 disorders: behavioral-variant FTD (bvFTD), semantic dementia, and progressive nonfluent aphasia.¹ Specifically, bvFTD can result in abnormal sexual behaviors such as making sexually inappropriate statements, masturbating in public, undressing in public, inappropriately or aggressively touching others, or confusing another individual as an intimate partner. In addition to cognitive impairment, these neurobehavioral symptoms can significantly impact an individual’s quality of life while increasing caregiver burden.²

Occurring at a similar frequency to Alzheimer’s disease in patients age <65, FTD is one of the more common causes of early-onset dementia. The mean age of onset is 58 and onset after age 75 is particularly unusual. Memory may not be affected early in the course of the disease, but social changes are likely. As FTD progresses, symptoms will resemble those of Alzheimer’s disease and patients will require assistance with activities of daily living. In later stages of FTD, patients will exhibit language and behavior symptoms. Due to its unique progression, FTD can be commonly misdiagnosed as other mental illnesses or neurocognitive disorders.¹

Approaches to treatment: What to consider

Both nonpharmacologic and pharmacologic interventions are appropriate for addressing FTD. Because nonpharmacologic options improve patient safety and overall physical health, they should be used whenever practical. These interventions include safe driving measures, exercise, speech therapy, redirection, offering simple choices when making decisions, and managing environmental cues for behaviors that should be encouraged or discouraged.³

There are no FDA-approved medications to cure or slow the progression of FTD. Therefore, treatment is focused on alleviating neurobehavioral symptoms. The symptoms depend on the type of FTD the patient has; they include cognitive impairment, anxiety, insomnia or sleep disturbances, compulsive behaviors, speech and language problems, and agitation. While many medications have been commonly used for symptomatic relief, evidence for the efficacy of these treatments in FTD is limited.²

Continue to: A review of the literature...

A review of the literature on potential treatments for cognitive impairment and behavioral symptoms of FTD identified 2 trials and 1 case series (Table 1^4-6) in addition to a 2014 review article⁷ of current pharmacologic treatments. These trials evaluated cognitive improvement with rivastigmine, memantine, galantamine, and donepezil. None of the trials found a significant benefit from any of these medications for cognitive improvement in FTD. Data were conflicting on whether these medications improved or worsened behavioral symptoms. For example, the case series of 3 patients by Swanberg⁶ suggested improvement in behavior with memantine, while an open-label study analyzed in a 2014 review article⁷ found that donepezil may have worsened behaviors. Use of cholinesterase inhibitors or memantine in FTD is not recommended unless it is not certain if the patient has FTD or Alzheimer’s disease.⁷

Addressing sexual behaviors. Creating a treatment regimen for FTD behavioral symptoms—specifically for abnormal sexual behaviors—can be challenging. Before starting pharmacotherapy directed at behavioral symptoms secondary to FTD, other causes of symptoms such as delirium, pain, or discomfort should be excluded. Nonpharmacologic approaches should be aimed at the type of sexual behavior and likely underlying environmental cause. For example, patients may inappropriately disrobe themselves. To address this behavior, hospital staff or caregivers should first eliminate environmental causes by ensuring the room is at a comfortable temperature, dressing the patient in light, breathable clothing, or checking if the patient needs to use the bathroom. If no environmental causes are found, a one-piece jumpsuit with closures on the back of the garment could be utilized to increase the difficulty of undressing.

Other nonpharmacologic methods include providing private areas for patients who are behaving inappropriately or removing potentially stimulating television or media from the environment. Another option is to increase the use of positive, pleasant stimuli. One approach that has shown benefit is music therapy, utilizing popular music genres from the patient’s youth.³

Evidence for pharmacotherapy is limited and largely from case reports and case series. A 2020 meta-analysis by Trieu et al⁸ reviewed 23 studies to expand on current clinical guidance for patients with bvFTD. These studies showed improvements in behavioral symptoms and reductions in caregiver fatigue with citalopram, trazodone, paroxetine, and fluvoxamine. Six of the trials included in this meta-analysis that evaluated these 4 medications are summarized in Table 2.^9-14 

Due to the lower risk of adverse effects and favorable safety profiles, SSRIs and trazodone are considered first-line treatment options. Benefit from these medications is theorized to be a result of their serotonergic effects, because serotonin abnormalities and dysfunction have been linked to FTD symptoms. For example, in a patient experiencing hypersexuality, the common adverse effect of low libido associated with SSRIs can be particularly beneficial.⁸

Continue to: Other medication classes studied in patients...

Other medication classes studied in patients with FTD include antipsychotics, stimulants, anticonvulsants, benzo­diazepines, and hormonal therapies. In addition to a black box warning for increased mortality in older patients with dementia-related psychosis, antipsychotics are associated with other serious adverse effects and should be used with caution.⁷

FTD is a debilitating disease that has a major impact on quality of life, particularly when behavioral symptoms accompany cognitive decline. Though some therapies may possibly improve behavioral symptoms, their routine use remains controversial due to a lack of clear evidence of benefit. In caring for patients with FTD and behavioral symptoms, a multimodal, team-based approach is vital.¹

CASE CONTINUED

The treatment team starts Mr. S on several of the modalities discussed in this article over the span of 2 years, with limited efficacy. Nonpharmacologic methods do not provide much benefit because Mr. S is extremely difficult to redirect. Given Mr. S’s past trials of SSRIs prior to admission, sertraline was retrialed and titrated over 2 years. The highest dose utilized during his admission was 200 mg/d. The team starts estrogen therapy but tapers and discontinues it due to ineffectiveness. Mr. S’s use of carbidopa/levodopa is thought to be contributing to his behavioral abnormalities, so the team tapers it to discontinuation; however, Mr. S’s sexually inappropriate behaviors and agitation continue. The team initiates a plan to reduce the dose of quetiapine and switch to gabapentin, but Mr. S fails gradual dose reduction due to his worsening behaviors. He starts gabapentin. The team gradually increases the dose of gabapentin to decrease libido and agitation, respectively. The increase in sertraline dose and use of nonpharmacologic modalities causes Mr. S’s use of as-needed antipsychotics to decrease.

Related Resources

• Ellison JM. What are the stages of frontotemporal dementia? BrightFocus Foundation. July 5, 2021. Accessed July 7, 2023. https://www.brightfocus.org/alzheimers/article/what-are-stages-frontotemporal-dementia
• Dementia and sexually inappropriate behavior. ReaDementia. January 31, 2022. Accessed July 7, 2023. https://readementia.com/dementia-and-sexually-inappropriate-behavior/

Drug Brand Names

Carbidopa/levodopa • Sinemet
Citalopram • Celexa
Donepezil • Aricept
Fluvoxamine • Luvox
Gabapentin • Neurontin
Galantamine • Razadyne
Memantine • Namenda
Paroxetine • Paxil
Quetiapine • Seroquel
Rivastigmine • Exelon
Sertraline • Zoloft
Trazodone • Desyrel

CASE TBI as a result of self-harm

Mr. N, age 46, presents to the emergency department (ED) after his neighbors report hearing “loud banging sounds” coming from his apartment for approximately 3 days. Emergency medical services found him repeatedly beating his head into a table. Upon admission to the ED, his injuries include a right temporal lobe contusion, right temporal subdural hematoma, facial fractures, bilateral foot fractures, and prevertebral swelling at the C4 vertebrate.

Mr. N is admitted to the surgical intensive care unit for hourly neurology checks. Neurosurgery recommends nonoperative management and for Mr. N to wear a cervical collar for 1 month. He is sedated after he experiences auditory hallucinations and becomes agitated toward the staff, which is later determined to be delirium. The Psychiatry team recommends inpatient psychiatric hospitalization because Mr. N’s self-harming behavior resulted in severe and dangerous injuries.

HISTORY Alcohol use disorder, insomnia, anxiety, and depression

As Mr. N becomes alert and oriented, he reports a history of alcohol use disorder (AUD), insomnia, anxiety, and major depressive disorder (MDD), but no personal or family history of bipolar disorder (BD). He says he has had insomnia and anxiety since age 18, for which he received diazepam and zolpidem for 16 years. He stopped diazepam soon after a recent change in psychiatrists and subsequently had difficulty sleeping. Mr. N started taking mirtazapine, but found minimal relief and stopped it several months ago.

[polldaddy:12704471]

The authors’ observations

The term “agitated depression” refers to a mixed state that includes symptoms of depression plus marked anxiety, restlessness, and delusions. Agitated depression is not a distinct diagnosis in DSM-5, but is classified as depression with mixed features.¹ To meet the criteria for the mixed features specifier, a patient who meets the criteria for a major depressive episode needs to have ≥3 of the following manic/hypomanic symptoms¹:

• Elevated, expansive mood
• Inflated self-esteem or grandiosity
• More talkative than usual
• Flight of ideas or racing thoughts
• Increase in energy or goal-directed activity
• Increased involvement in activities that have a high potential for painful consequences
• Decreased need for sleep.

The diagnosis for individuals who meet the full criteria for mania or hypomania would be BD I or BD II.¹ Additionally, mixed features associated with a major depressive episode are a significant risk factor for BD.¹

EVALUATION Agitation and hallucinations

Mr. N recalls multiple falls at home in the weeks prior to hospitalization, but says he does not remember repeatedly hitting his head against a table. He reports sleeping for approximately 2 hours per night since his father’s death 2 months ago, an acute stressor that likely precipitated this depressive episode. Mr. N says he had been experiencing visual hallucinations of his father and a younger version of himself for weeks before presenting to the ED. It is not clear if Mr. N does not recall beating his head on the table due to his traumatic brain injury (TBI) or because it occurred during an acute manic or psychotic episode with hallucinations.

The treatment team assigns Mr. N a working diagnosis of agitated depression with a risk for BD, mixed episode. He meets the criteria for agitated depression (major depressive episode, motor agitation, and psychic agitation), but also has many features of BD; a manic episode may have led to hospitalization. The treating clinicians continue to monitor the progression of Mr. N’s symptoms to clarify his diagnoses. During the course of his hospitalization, Mr. N’s psychiatric diagnoses include delirium (resolved), alcohol withdrawal, catatonia, substance-induced mood disorder, and agitated depression. Mixed episode BD is ruled out.

Continue to: The authors' observations

There is significant symptomatic overlap between agitated depression and BD. It can be difficult to differentiate the diagnoses, as psychomotor agitation can be seen in MDD and agitated depression can be seen in BD. Serra et al² investigated the prevalence of agitated depression in patients with BD and found that agitation accompanied bipolar depression in at least one-third of cases and was associated with concurrent somatic depressive symptoms, which are common features of mixed manic states. Psychomotor agitation was also associated with lifetime experience of mixed mania, comorbid panic disorder, and increased suicidal behavior.²

Though antidepressants are considered a first-line treatment for depression, they should not be used to treat agitated depression because they may increase insomnia, agitation, and suicide risk, and may trigger the onset of psychotic symptoms. In a similar vein, antidepressant monotherapy is contraindicated in BD because it may induce mania or hypomania states.²

TREATMENT Neuroprotective psychotropics

Due to Mr. N’s medical complexity (particularly cervical collar and physical therapy needs), he is not transferred to a psychiatric facility. Instead, the consultation-liaison psychiatry team follows him and provides psychiatric care in the hospital.

Due to concerns for continued self-harm, Mr. N is observed by continuous video monitoring. After initial stabilization, the care team starts valproic acid 250 mg twice daily and titrates it to 500 mg/d in the morning and 1,000 mg/d in the evening for mood stabilization, gabapentin 300 mg 3 times daily, melatonin 3 mg/d at bedtime for insomnia, and lorazepam 1 mg/d at bedtime to rule out catatonia and 1 mg/d as needed for agitation. After starting valproic acid, the care team routinely checks Mr. N’s ammonia levels throughout his hospitalization.

[polldaddy:12704473]

The authors’ observations

Treatment of agitated depression both in isolation and in the context of BD presents a clinical challenge because antidepressants are contraindicated for both agitated depression and BD. In the context of TBI, treatment of agitated depression becomes more complicated because neuroprotection is the priority. Neuroprotection refers to a medication’s ability to prevent neuronal cell death or further injury or damage through neurochemical modulation.

Continue to: To treat agitation associated with MDD...

To treat agitation associated with MDD, second-generation antipsychotics and valproic acid have shown significant neuroprotective effects. The proposed mechanisms for neuroprotection include not only antioxidant effects but 5HT1A agonist properties, with the latter thought to protect against excitotoxic injury that may exacerbate agitation due to brain trauma.³

There is no consensus on which antipsychotics are most efficacious for treating agitation in the setting of an acute TBI. Williamson et al⁴ reviewed various medications that may treat agitation in the setting of acute TBI with fewer adverse effects.

Though haloperidol is often prescribed to treat agitation in patients with TBI, animal studies have shown it is inferior to second-generation antipsychotics in protecting against excitotoxic/oxidative injury, and haloperidol has been associated with neuronal loss. Haloperidol has been linked to adverse clinical outcomes for patients with aggression after TBI, including prolonged amnesia, which is thought to be linked to haloperidol’s strong and selective dopamine-2 receptor antagonism and the mesocortical and nigrostriatal pathways involved.⁴ 

Carbamazepine, phenytoin, and methyl­phenidate cause oxidative stress and/or apoptosis, and therefore offer no neuroprotection. Data on gabapentin are mixed; a few studies suggest it may block synapse formation or decrease quantities of antioxidant enzymes in the brain, though it’s known to protect against glutamate-induced neuronal injury.³

Additional research is needed to assess which second-generation antipsychotics offer the most neuroprotection. However, based on existing literature, olanzapine and aripiprazole may offer the most benefit because they have the greatest antioxidant—and thus, neuroprotective—activity. Cognitive enhancers such as memantine and donepezil exhibit neuroprotection, particularly in Alzheimer disease. Anticonvulsants such as levetiracetam, lacosamide, and lamotrigine offer neuroprotection and may be considered for seizure prevention.³ The Table^3-6 lists psychotropic medications used to treat TBI.

Continue to: Valproic acid stands out among...

Valproic acid stands out among anticonvulsants because its superior antioxidant effects, in combination with its antiepileptic effect in patients with TBI, offer more neuro­protection than other medications.⁵ It is important to regularly monitor ammonia levels in patients receiving valproic acid because elevated levels can cause hyperammonemic encephalopathy.

A 2005 study by DeBattista et al⁵ investigated the impact of valproic acid on agitation in 12 adults with MDD who were being treated with antidepressants. Participants were given a low dose of valproic acid for 4 weeks and their agitation, anxiety, and depressed mood were independently assessed by separate rating scales. There was a modest decrease in scores for mood symptoms but a particularly sharp decrease in agitation scores.⁵

Valproic acid has been shown to be a potentially safe and efficacious treatment for alcohol withdrawal. A clinical trial examining patients with moderate alcohol withdrawal found a faster and more consistent resolution of symptoms in patients given valproic acid detoxification compared to a control group that received the standard benzodiazepine detoxification.⁶ Additionally, patients who continued maintenance valproic acid following detoxification were completely abstinent at 6-week follow-up compared to patients who did not receive this maintenance therapy.⁶ 

Valproic acid was a particularly optimal medication choice for Mr. N due to its neuroprotective properties in the context of TBI, its ability to treat delirium,⁷ its lack of abuse potential compared with benzodiazepines, and its potential efficacy for managing alcohol withdrawal and AUD.

OUTCOME Improvement and discharge

Mr. N is medically cleared for discharge. Although the psychiatry team initially was concerned about his willingness to attend follow-up appointments and adhere to proper cervical collar use, Mr. N becomes more cooperative with psychiatric care as his stay continues, and he is psychiatrically cleared for discharge 1 month after admission. Discharge plans include attending an intensive outpatient program, continuing the inpatient psychiatric medication regimen, participating in regular outpatient psychiatric follow-up, as well as following up with orthopedic surgery, neurosurgery, podiatry, and ear, nose, and throat for medical conditions.

Bottom Line

Agitated depression is a mixed state that includes features of depression and manic/hypomanic symptoms. Diagnosis and treatment can be challenging because symptoms of agitated depression overlap with bipolar disorder and antidepressants are contraindicated. In a patient with a traumatic brain injury, pharmacotherapy that provides neuroprotection is a priority.

Related Resources

• Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
• Sampogna G, Del Vecchio V, Giallonardo V, et al. Diagnosis, clinical features, and therapeutic implications of agitated depression. Psychiatr Clin North Am. 2020;43(1):47-57. doi: 10.1016/j.psc.2019.10.011

Drug Brand Names

Amantadine • Gocovri
Aripiprazole • Abilify
Asenapine • Saphris
Brexpiprazole • Rexulti
Buspirone • BuSpar
Carbamazepine • Tegretol
Cariprazine • Vraylar
Clozapine • Clozaril
Dexmedetomidine • Igalmi
Diazepam • Valium
Donepezil • Aricept
Gabapentin • Neurontin
Haloperidol • Haldol
Ketamine • Ketalar
Lacosamide • Vimpat
Lamotrigine • Lamictal
Levetiracetam • Keppra
Lithium • Lithobid
Lorazepam • Ativan
Lurasidone • Latuda
Memantine • Namenda
Methylphenidate • Concerta
Mirtazapine • Remeron
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Paliperidone • Invega
Phenytoin • Dilantin
Pramipexole • Mirapex
Pregabalin • Lyrica
Quetiapine • Seroquel
Risperidone • Risperdal
Trazodone • Oleptro
Valproic acid • Depakene
Ziprasidone • Geodon
Zolpidem • Ambien
Zonisamide • Zonegran

CASE TBI as a result of self-harm

Mr. N, age 46, presents to the emergency department (ED) after his neighbors report hearing “loud banging sounds” coming from his apartment for approximately 3 days. Emergency medical services found him repeatedly beating his head into a table. Upon admission to the ED, his injuries include a right temporal lobe contusion, right temporal subdural hematoma, facial fractures, bilateral foot fractures, and prevertebral swelling at the C4 vertebrate.

Mr. N is admitted to the surgical intensive care unit for hourly neurology checks. Neurosurgery recommends nonoperative management and for Mr. N to wear a cervical collar for 1 month. He is sedated after he experiences auditory hallucinations and becomes agitated toward the staff, which is later determined to be delirium. The Psychiatry team recommends inpatient psychiatric hospitalization because Mr. N’s self-harming behavior resulted in severe and dangerous injuries.

HISTORY Alcohol use disorder, insomnia, anxiety, and depression

As Mr. N becomes alert and oriented, he reports a history of alcohol use disorder (AUD), insomnia, anxiety, and major depressive disorder (MDD), but no personal or family history of bipolar disorder (BD). He says he has had insomnia and anxiety since age 18, for which he received diazepam and zolpidem for 16 years. He stopped diazepam soon after a recent change in psychiatrists and subsequently had difficulty sleeping. Mr. N started taking mirtazapine, but found minimal relief and stopped it several months ago.

[polldaddy:12704471]

The authors’ observations

The term “agitated depression” refers to a mixed state that includes symptoms of depression plus marked anxiety, restlessness, and delusions. Agitated depression is not a distinct diagnosis in DSM-5, but is classified as depression with mixed features.¹ To meet the criteria for the mixed features specifier, a patient who meets the criteria for a major depressive episode needs to have ≥3 of the following manic/hypomanic symptoms¹:

• Elevated, expansive mood
• Inflated self-esteem or grandiosity
• More talkative than usual
• Flight of ideas or racing thoughts
• Increase in energy or goal-directed activity
• Increased involvement in activities that have a high potential for painful consequences
• Decreased need for sleep.

The diagnosis for individuals who meet the full criteria for mania or hypomania would be BD I or BD II.¹ Additionally, mixed features associated with a major depressive episode are a significant risk factor for BD.¹

EVALUATION Agitation and hallucinations

Mr. N recalls multiple falls at home in the weeks prior to hospitalization, but says he does not remember repeatedly hitting his head against a table. He reports sleeping for approximately 2 hours per night since his father’s death 2 months ago, an acute stressor that likely precipitated this depressive episode. Mr. N says he had been experiencing visual hallucinations of his father and a younger version of himself for weeks before presenting to the ED. It is not clear if Mr. N does not recall beating his head on the table due to his traumatic brain injury (TBI) or because it occurred during an acute manic or psychotic episode with hallucinations.

The treatment team assigns Mr. N a working diagnosis of agitated depression with a risk for BD, mixed episode. He meets the criteria for agitated depression (major depressive episode, motor agitation, and psychic agitation), but also has many features of BD; a manic episode may have led to hospitalization. The treating clinicians continue to monitor the progression of Mr. N’s symptoms to clarify his diagnoses. During the course of his hospitalization, Mr. N’s psychiatric diagnoses include delirium (resolved), alcohol withdrawal, catatonia, substance-induced mood disorder, and agitated depression. Mixed episode BD is ruled out.

Continue to: The authors' observations

There is significant symptomatic overlap between agitated depression and BD. It can be difficult to differentiate the diagnoses, as psychomotor agitation can be seen in MDD and agitated depression can be seen in BD. Serra et al² investigated the prevalence of agitated depression in patients with BD and found that agitation accompanied bipolar depression in at least one-third of cases and was associated with concurrent somatic depressive symptoms, which are common features of mixed manic states. Psychomotor agitation was also associated with lifetime experience of mixed mania, comorbid panic disorder, and increased suicidal behavior.²

Though antidepressants are considered a first-line treatment for depression, they should not be used to treat agitated depression because they may increase insomnia, agitation, and suicide risk, and may trigger the onset of psychotic symptoms. In a similar vein, antidepressant monotherapy is contraindicated in BD because it may induce mania or hypomania states.²

TREATMENT Neuroprotective psychotropics

Due to Mr. N’s medical complexity (particularly cervical collar and physical therapy needs), he is not transferred to a psychiatric facility. Instead, the consultation-liaison psychiatry team follows him and provides psychiatric care in the hospital.

Due to concerns for continued self-harm, Mr. N is observed by continuous video monitoring. After initial stabilization, the care team starts valproic acid 250 mg twice daily and titrates it to 500 mg/d in the morning and 1,000 mg/d in the evening for mood stabilization, gabapentin 300 mg 3 times daily, melatonin 3 mg/d at bedtime for insomnia, and lorazepam 1 mg/d at bedtime to rule out catatonia and 1 mg/d as needed for agitation. After starting valproic acid, the care team routinely checks Mr. N’s ammonia levels throughout his hospitalization.

[polldaddy:12704473]

The authors’ observations

Treatment of agitated depression both in isolation and in the context of BD presents a clinical challenge because antidepressants are contraindicated for both agitated depression and BD. In the context of TBI, treatment of agitated depression becomes more complicated because neuroprotection is the priority. Neuroprotection refers to a medication’s ability to prevent neuronal cell death or further injury or damage through neurochemical modulation.

Continue to: To treat agitation associated with MDD...

To treat agitation associated with MDD, second-generation antipsychotics and valproic acid have shown significant neuroprotective effects. The proposed mechanisms for neuroprotection include not only antioxidant effects but 5HT1A agonist properties, with the latter thought to protect against excitotoxic injury that may exacerbate agitation due to brain trauma.³

There is no consensus on which antipsychotics are most efficacious for treating agitation in the setting of an acute TBI. Williamson et al⁴ reviewed various medications that may treat agitation in the setting of acute TBI with fewer adverse effects.

Though haloperidol is often prescribed to treat agitation in patients with TBI, animal studies have shown it is inferior to second-generation antipsychotics in protecting against excitotoxic/oxidative injury, and haloperidol has been associated with neuronal loss. Haloperidol has been linked to adverse clinical outcomes for patients with aggression after TBI, including prolonged amnesia, which is thought to be linked to haloperidol’s strong and selective dopamine-2 receptor antagonism and the mesocortical and nigrostriatal pathways involved.⁴ 

Carbamazepine, phenytoin, and methyl­phenidate cause oxidative stress and/or apoptosis, and therefore offer no neuroprotection. Data on gabapentin are mixed; a few studies suggest it may block synapse formation or decrease quantities of antioxidant enzymes in the brain, though it’s known to protect against glutamate-induced neuronal injury.³

Additional research is needed to assess which second-generation antipsychotics offer the most neuroprotection. However, based on existing literature, olanzapine and aripiprazole may offer the most benefit because they have the greatest antioxidant—and thus, neuroprotective—activity. Cognitive enhancers such as memantine and donepezil exhibit neuroprotection, particularly in Alzheimer disease. Anticonvulsants such as levetiracetam, lacosamide, and lamotrigine offer neuroprotection and may be considered for seizure prevention.³ The Table^3-6 lists psychotropic medications used to treat TBI.

Continue to: Valproic acid stands out among...

Valproic acid stands out among anticonvulsants because its superior antioxidant effects, in combination with its antiepileptic effect in patients with TBI, offer more neuro­protection than other medications.⁵ It is important to regularly monitor ammonia levels in patients receiving valproic acid because elevated levels can cause hyperammonemic encephalopathy.

A 2005 study by DeBattista et al⁵ investigated the impact of valproic acid on agitation in 12 adults with MDD who were being treated with antidepressants. Participants were given a low dose of valproic acid for 4 weeks and their agitation, anxiety, and depressed mood were independently assessed by separate rating scales. There was a modest decrease in scores for mood symptoms but a particularly sharp decrease in agitation scores.⁵

Valproic acid has been shown to be a potentially safe and efficacious treatment for alcohol withdrawal. A clinical trial examining patients with moderate alcohol withdrawal found a faster and more consistent resolution of symptoms in patients given valproic acid detoxification compared to a control group that received the standard benzodiazepine detoxification.⁶ Additionally, patients who continued maintenance valproic acid following detoxification were completely abstinent at 6-week follow-up compared to patients who did not receive this maintenance therapy.⁶ 

Valproic acid was a particularly optimal medication choice for Mr. N due to its neuroprotective properties in the context of TBI, its ability to treat delirium,⁷ its lack of abuse potential compared with benzodiazepines, and its potential efficacy for managing alcohol withdrawal and AUD.

OUTCOME Improvement and discharge

Mr. N is medically cleared for discharge. Although the psychiatry team initially was concerned about his willingness to attend follow-up appointments and adhere to proper cervical collar use, Mr. N becomes more cooperative with psychiatric care as his stay continues, and he is psychiatrically cleared for discharge 1 month after admission. Discharge plans include attending an intensive outpatient program, continuing the inpatient psychiatric medication regimen, participating in regular outpatient psychiatric follow-up, as well as following up with orthopedic surgery, neurosurgery, podiatry, and ear, nose, and throat for medical conditions.

Bottom Line

Agitated depression is a mixed state that includes features of depression and manic/hypomanic symptoms. Diagnosis and treatment can be challenging because symptoms of agitated depression overlap with bipolar disorder and antidepressants are contraindicated. In a patient with a traumatic brain injury, pharmacotherapy that provides neuroprotection is a priority.

Related Resources

• Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
• Sampogna G, Del Vecchio V, Giallonardo V, et al. Diagnosis, clinical features, and therapeutic implications of agitated depression. Psychiatr Clin North Am. 2020;43(1):47-57. doi: 10.1016/j.psc.2019.10.011

Drug Brand Names

Amantadine • Gocovri
Aripiprazole • Abilify
Asenapine • Saphris
Brexpiprazole • Rexulti
Buspirone • BuSpar
Carbamazepine • Tegretol
Cariprazine • Vraylar
Clozapine • Clozaril
Dexmedetomidine • Igalmi
Diazepam • Valium
Donepezil • Aricept
Gabapentin • Neurontin
Haloperidol • Haldol
Ketamine • Ketalar
Lacosamide • Vimpat
Lamotrigine • Lamictal
Levetiracetam • Keppra
Lithium • Lithobid
Lorazepam • Ativan
Lurasidone • Latuda
Memantine • Namenda
Methylphenidate • Concerta
Mirtazapine • Remeron
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Paliperidone • Invega
Phenytoin • Dilantin
Pramipexole • Mirapex
Pregabalin • Lyrica
Quetiapine • Seroquel
Risperidone • Risperdal
Trazodone • Oleptro
Valproic acid • Depakene
Ziprasidone • Geodon
Zolpidem • Ambien
Zonisamide • Zonegran

CASE TBI as a result of self-harm

Mr. N, age 46, presents to the emergency department (ED) after his neighbors report hearing “loud banging sounds” coming from his apartment for approximately 3 days. Emergency medical services found him repeatedly beating his head into a table. Upon admission to the ED, his injuries include a right temporal lobe contusion, right temporal subdural hematoma, facial fractures, bilateral foot fractures, and prevertebral swelling at the C4 vertebrate.

Mr. N is admitted to the surgical intensive care unit for hourly neurology checks. Neurosurgery recommends nonoperative management and for Mr. N to wear a cervical collar for 1 month. He is sedated after he experiences auditory hallucinations and becomes agitated toward the staff, which is later determined to be delirium. The Psychiatry team recommends inpatient psychiatric hospitalization because Mr. N’s self-harming behavior resulted in severe and dangerous injuries.

HISTORY Alcohol use disorder, insomnia, anxiety, and depression

As Mr. N becomes alert and oriented, he reports a history of alcohol use disorder (AUD), insomnia, anxiety, and major depressive disorder (MDD), but no personal or family history of bipolar disorder (BD). He says he has had insomnia and anxiety since age 18, for which he received diazepam and zolpidem for 16 years. He stopped diazepam soon after a recent change in psychiatrists and subsequently had difficulty sleeping. Mr. N started taking mirtazapine, but found minimal relief and stopped it several months ago.

[polldaddy:12704471]

The authors’ observations

The term “agitated depression” refers to a mixed state that includes symptoms of depression plus marked anxiety, restlessness, and delusions. Agitated depression is not a distinct diagnosis in DSM-5, but is classified as depression with mixed features.¹ To meet the criteria for the mixed features specifier, a patient who meets the criteria for a major depressive episode needs to have ≥3 of the following manic/hypomanic symptoms¹:

• Elevated, expansive mood
• Inflated self-esteem or grandiosity
• More talkative than usual
• Flight of ideas or racing thoughts
• Increase in energy or goal-directed activity
• Increased involvement in activities that have a high potential for painful consequences
• Decreased need for sleep.

The diagnosis for individuals who meet the full criteria for mania or hypomania would be BD I or BD II.¹ Additionally, mixed features associated with a major depressive episode are a significant risk factor for BD.¹

EVALUATION Agitation and hallucinations

Mr. N recalls multiple falls at home in the weeks prior to hospitalization, but says he does not remember repeatedly hitting his head against a table. He reports sleeping for approximately 2 hours per night since his father’s death 2 months ago, an acute stressor that likely precipitated this depressive episode. Mr. N says he had been experiencing visual hallucinations of his father and a younger version of himself for weeks before presenting to the ED. It is not clear if Mr. N does not recall beating his head on the table due to his traumatic brain injury (TBI) or because it occurred during an acute manic or psychotic episode with hallucinations.

The treatment team assigns Mr. N a working diagnosis of agitated depression with a risk for BD, mixed episode. He meets the criteria for agitated depression (major depressive episode, motor agitation, and psychic agitation), but also has many features of BD; a manic episode may have led to hospitalization. The treating clinicians continue to monitor the progression of Mr. N’s symptoms to clarify his diagnoses. During the course of his hospitalization, Mr. N’s psychiatric diagnoses include delirium (resolved), alcohol withdrawal, catatonia, substance-induced mood disorder, and agitated depression. Mixed episode BD is ruled out.

Continue to: The authors' observations

There is significant symptomatic overlap between agitated depression and BD. It can be difficult to differentiate the diagnoses, as psychomotor agitation can be seen in MDD and agitated depression can be seen in BD. Serra et al² investigated the prevalence of agitated depression in patients with BD and found that agitation accompanied bipolar depression in at least one-third of cases and was associated with concurrent somatic depressive symptoms, which are common features of mixed manic states. Psychomotor agitation was also associated with lifetime experience of mixed mania, comorbid panic disorder, and increased suicidal behavior.²

Though antidepressants are considered a first-line treatment for depression, they should not be used to treat agitated depression because they may increase insomnia, agitation, and suicide risk, and may trigger the onset of psychotic symptoms. In a similar vein, antidepressant monotherapy is contraindicated in BD because it may induce mania or hypomania states.²

TREATMENT Neuroprotective psychotropics

Due to Mr. N’s medical complexity (particularly cervical collar and physical therapy needs), he is not transferred to a psychiatric facility. Instead, the consultation-liaison psychiatry team follows him and provides psychiatric care in the hospital.

Due to concerns for continued self-harm, Mr. N is observed by continuous video monitoring. After initial stabilization, the care team starts valproic acid 250 mg twice daily and titrates it to 500 mg/d in the morning and 1,000 mg/d in the evening for mood stabilization, gabapentin 300 mg 3 times daily, melatonin 3 mg/d at bedtime for insomnia, and lorazepam 1 mg/d at bedtime to rule out catatonia and 1 mg/d as needed for agitation. After starting valproic acid, the care team routinely checks Mr. N’s ammonia levels throughout his hospitalization.

[polldaddy:12704473]

The authors’ observations

Treatment of agitated depression both in isolation and in the context of BD presents a clinical challenge because antidepressants are contraindicated for both agitated depression and BD. In the context of TBI, treatment of agitated depression becomes more complicated because neuroprotection is the priority. Neuroprotection refers to a medication’s ability to prevent neuronal cell death or further injury or damage through neurochemical modulation.

Continue to: To treat agitation associated with MDD...

To treat agitation associated with MDD, second-generation antipsychotics and valproic acid have shown significant neuroprotective effects. The proposed mechanisms for neuroprotection include not only antioxidant effects but 5HT1A agonist properties, with the latter thought to protect against excitotoxic injury that may exacerbate agitation due to brain trauma.³

There is no consensus on which antipsychotics are most efficacious for treating agitation in the setting of an acute TBI. Williamson et al⁴ reviewed various medications that may treat agitation in the setting of acute TBI with fewer adverse effects.

Though haloperidol is often prescribed to treat agitation in patients with TBI, animal studies have shown it is inferior to second-generation antipsychotics in protecting against excitotoxic/oxidative injury, and haloperidol has been associated with neuronal loss. Haloperidol has been linked to adverse clinical outcomes for patients with aggression after TBI, including prolonged amnesia, which is thought to be linked to haloperidol’s strong and selective dopamine-2 receptor antagonism and the mesocortical and nigrostriatal pathways involved.⁴ 

Carbamazepine, phenytoin, and methyl­phenidate cause oxidative stress and/or apoptosis, and therefore offer no neuroprotection. Data on gabapentin are mixed; a few studies suggest it may block synapse formation or decrease quantities of antioxidant enzymes in the brain, though it’s known to protect against glutamate-induced neuronal injury.³

Additional research is needed to assess which second-generation antipsychotics offer the most neuroprotection. However, based on existing literature, olanzapine and aripiprazole may offer the most benefit because they have the greatest antioxidant—and thus, neuroprotective—activity. Cognitive enhancers such as memantine and donepezil exhibit neuroprotection, particularly in Alzheimer disease. Anticonvulsants such as levetiracetam, lacosamide, and lamotrigine offer neuroprotection and may be considered for seizure prevention.³ The Table^3-6 lists psychotropic medications used to treat TBI.

Continue to: Valproic acid stands out among...

Valproic acid stands out among anticonvulsants because its superior antioxidant effects, in combination with its antiepileptic effect in patients with TBI, offer more neuro­protection than other medications.⁵ It is important to regularly monitor ammonia levels in patients receiving valproic acid because elevated levels can cause hyperammonemic encephalopathy.

A 2005 study by DeBattista et al⁵ investigated the impact of valproic acid on agitation in 12 adults with MDD who were being treated with antidepressants. Participants were given a low dose of valproic acid for 4 weeks and their agitation, anxiety, and depressed mood were independently assessed by separate rating scales. There was a modest decrease in scores for mood symptoms but a particularly sharp decrease in agitation scores.⁵

Valproic acid has been shown to be a potentially safe and efficacious treatment for alcohol withdrawal. A clinical trial examining patients with moderate alcohol withdrawal found a faster and more consistent resolution of symptoms in patients given valproic acid detoxification compared to a control group that received the standard benzodiazepine detoxification.⁶ Additionally, patients who continued maintenance valproic acid following detoxification were completely abstinent at 6-week follow-up compared to patients who did not receive this maintenance therapy.⁶ 

Valproic acid was a particularly optimal medication choice for Mr. N due to its neuroprotective properties in the context of TBI, its ability to treat delirium,⁷ its lack of abuse potential compared with benzodiazepines, and its potential efficacy for managing alcohol withdrawal and AUD.

OUTCOME Improvement and discharge

Mr. N is medically cleared for discharge. Although the psychiatry team initially was concerned about his willingness to attend follow-up appointments and adhere to proper cervical collar use, Mr. N becomes more cooperative with psychiatric care as his stay continues, and he is psychiatrically cleared for discharge 1 month after admission. Discharge plans include attending an intensive outpatient program, continuing the inpatient psychiatric medication regimen, participating in regular outpatient psychiatric follow-up, as well as following up with orthopedic surgery, neurosurgery, podiatry, and ear, nose, and throat for medical conditions.

Bottom Line

Agitated depression is a mixed state that includes features of depression and manic/hypomanic symptoms. Diagnosis and treatment can be challenging because symptoms of agitated depression overlap with bipolar disorder and antidepressants are contraindicated. In a patient with a traumatic brain injury, pharmacotherapy that provides neuroprotection is a priority.

Related Resources

• Ramaswamy S, Driscoll D, Rodriguez A, et al. Nutraceuticals for traumatic brain injury: should you recommend their use? Current Psychiatry. 2017;16(7):34-38,40,41-45.
• Sampogna G, Del Vecchio V, Giallonardo V, et al. Diagnosis, clinical features, and therapeutic implications of agitated depression. Psychiatr Clin North Am. 2020;43(1):47-57. doi: 10.1016/j.psc.2019.10.011

Drug Brand Names

Amantadine • Gocovri
Aripiprazole • Abilify
Asenapine • Saphris
Brexpiprazole • Rexulti
Buspirone • BuSpar
Carbamazepine • Tegretol
Cariprazine • Vraylar
Clozapine • Clozaril
Dexmedetomidine • Igalmi
Diazepam • Valium
Donepezil • Aricept
Gabapentin • Neurontin
Haloperidol • Haldol
Ketamine • Ketalar
Lacosamide • Vimpat
Lamotrigine • Lamictal
Levetiracetam • Keppra
Lithium • Lithobid
Lorazepam • Ativan
Lurasidone • Latuda
Memantine • Namenda
Methylphenidate • Concerta
Mirtazapine • Remeron
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Paliperidone • Invega
Phenytoin • Dilantin
Pramipexole • Mirapex
Pregabalin • Lyrica
Quetiapine • Seroquel
Risperidone • Risperdal
Trazodone • Oleptro
Valproic acid • Depakene
Ziprasidone • Geodon
Zolpidem • Ambien
Zonisamide • Zonegran

Psychiatric clinicians may unilaterally decide to end a treatment relationship with a patient when the relationship is no longer therapeutic, such as when the patient does not adhere to treatment, repeatedly misses appointments, exhibits abusive behaviors, or fails to pay for treatment.¹ Claims of abandonment can arise if ending the treatment relationship is not executed properly. Abandonment is the termination of a treatment relationship with a patient who remains in need of treatment, has no suitable substitute treatment, and subsequently experiences damages as a result of the termination.² When a patient terminates a treatment relationship, there are no legal bases for abandonment claims.³ In this article, I provide a few practical tips for properly terminating the doctor-patient relationship to limit the likelihood of claims of abandonment.

Know your jurisdiction’s requirements for terminating the relationship. Each state has its own legal definition of a doctor-patient relationship as well as requirements for ending it. Abandonment claims are unfounded in the absence of a doctor-patient relationship.³ Contact the appropriate licensing board to determine what your state’s regulatory requirements are. If necessary, consult with your attorney or a risk management professional for guidance.⁴

Communicate clearly. Communicate with your patient about the end of the treatment relationship in a clear and consistent manner, both verbally and in writing, because a termination should be viewed as a formal, documented event.³ Except in situations requiring immediate termination, psychiatric clinicians should inform the patient about the reason(s) for termination,⁴ the need for continued treatment,³ and the type of recommended treatment.³ This discussion should be summarized in a termination letter given to the patient that includes termination language, referral sources, the end date of treatment, and a request for authorization to release a copy of the patient’s medical records to their new clinician.^3,4

Give adequate time, set boundaries, and document. Thirty days is generally considered adequate time for a patient to find a new clinician,⁵ unless the patient lives in an area where there is a shortage of psychiatric clinicians, in which case a longer time period would be appropriate.³ Ensure your patient has a sufficient supply of medication(s) until they establish care with a new clinician.⁴ Offer to provide emergency care for a reasonable period of time during the termination process unless a safety concern requires immediate termination.⁴ Avoid situations in which the patient attempts to re-enter your care. Document the reason for the termination in your progress notes and keep a copy of the termination letter in the patient’s medical record.⁴

Psychiatric clinicians may unilaterally decide to end a treatment relationship with a patient when the relationship is no longer therapeutic, such as when the patient does not adhere to treatment, repeatedly misses appointments, exhibits abusive behaviors, or fails to pay for treatment.¹ Claims of abandonment can arise if ending the treatment relationship is not executed properly. Abandonment is the termination of a treatment relationship with a patient who remains in need of treatment, has no suitable substitute treatment, and subsequently experiences damages as a result of the termination.² When a patient terminates a treatment relationship, there are no legal bases for abandonment claims.³ In this article, I provide a few practical tips for properly terminating the doctor-patient relationship to limit the likelihood of claims of abandonment.

Know your jurisdiction’s requirements for terminating the relationship. Each state has its own legal definition of a doctor-patient relationship as well as requirements for ending it. Abandonment claims are unfounded in the absence of a doctor-patient relationship.³ Contact the appropriate licensing board to determine what your state’s regulatory requirements are. If necessary, consult with your attorney or a risk management professional for guidance.⁴

Communicate clearly. Communicate with your patient about the end of the treatment relationship in a clear and consistent manner, both verbally and in writing, because a termination should be viewed as a formal, documented event.³ Except in situations requiring immediate termination, psychiatric clinicians should inform the patient about the reason(s) for termination,⁴ the need for continued treatment,³ and the type of recommended treatment.³ This discussion should be summarized in a termination letter given to the patient that includes termination language, referral sources, the end date of treatment, and a request for authorization to release a copy of the patient’s medical records to their new clinician.^3,4

Give adequate time, set boundaries, and document. Thirty days is generally considered adequate time for a patient to find a new clinician,⁵ unless the patient lives in an area where there is a shortage of psychiatric clinicians, in which case a longer time period would be appropriate.³ Ensure your patient has a sufficient supply of medication(s) until they establish care with a new clinician.⁴ Offer to provide emergency care for a reasonable period of time during the termination process unless a safety concern requires immediate termination.⁴ Avoid situations in which the patient attempts to re-enter your care. Document the reason for the termination in your progress notes and keep a copy of the termination letter in the patient’s medical record.⁴

Psychiatric clinicians may unilaterally decide to end a treatment relationship with a patient when the relationship is no longer therapeutic, such as when the patient does not adhere to treatment, repeatedly misses appointments, exhibits abusive behaviors, or fails to pay for treatment.¹ Claims of abandonment can arise if ending the treatment relationship is not executed properly. Abandonment is the termination of a treatment relationship with a patient who remains in need of treatment, has no suitable substitute treatment, and subsequently experiences damages as a result of the termination.² When a patient terminates a treatment relationship, there are no legal bases for abandonment claims.³ In this article, I provide a few practical tips for properly terminating the doctor-patient relationship to limit the likelihood of claims of abandonment.

Know your jurisdiction’s requirements for terminating the relationship. Each state has its own legal definition of a doctor-patient relationship as well as requirements for ending it. Abandonment claims are unfounded in the absence of a doctor-patient relationship.³ Contact the appropriate licensing board to determine what your state’s regulatory requirements are. If necessary, consult with your attorney or a risk management professional for guidance.⁴

Communicate clearly. Communicate with your patient about the end of the treatment relationship in a clear and consistent manner, both verbally and in writing, because a termination should be viewed as a formal, documented event.³ Except in situations requiring immediate termination, psychiatric clinicians should inform the patient about the reason(s) for termination,⁴ the need for continued treatment,³ and the type of recommended treatment.³ This discussion should be summarized in a termination letter given to the patient that includes termination language, referral sources, the end date of treatment, and a request for authorization to release a copy of the patient’s medical records to their new clinician.^3,4

Give adequate time, set boundaries, and document. Thirty days is generally considered adequate time for a patient to find a new clinician,⁵ unless the patient lives in an area where there is a shortage of psychiatric clinicians, in which case a longer time period would be appropriate.³ Ensure your patient has a sufficient supply of medication(s) until they establish care with a new clinician.⁴ Offer to provide emergency care for a reasonable period of time during the termination process unless a safety concern requires immediate termination.⁴ Avoid situations in which the patient attempts to re-enter your care. Document the reason for the termination in your progress notes and keep a copy of the termination letter in the patient’s medical record.⁴

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry. All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more information, contact letters@currentpsychiatry.com.

Creating an optimal learning environment for medical students studying psychiatry is essential for their growth and development. Over the last 25 years, I have worked with hundreds of medical students in a busy urban emergency department (ED), and I have developed a style that has worked well for them and for me. A supportive, engaging atmosphere can significantly enhance students’ understanding of psychiatric conditions, therapeutic approaches, and patient care. To ensure a productive and inspiring learning experience, educators should consider several key factors.

The educators

Faculty physicians should invest themselves in the students’ individual growth and aspirations by providing personalized guidance that caters to each student’s goals and challenges.¹ Educators must also embody a passion for psychiatry. I’ve found that integrating a lighthearted and humorous approach to my teaching style can relieve stress and enhance learning. I’ve also found it crucial to demonstrate empathy and effective communication skills that students can emulate in their professional development.² Encourage students to take an active role in their learning process by engaging in clinical discussions and decision-making. Lastly, providing regular assessments and constructive feedback in a supportive manner allows students to better understand their strengths and weaknesses, and to continually improve their knowledge and skills.³

The students

Encourage students to fully express their unique personalities, perspectives, and learning styles. This diversity can fuel creativity and promote an atmosphere of inclusivity and enhanced learning. Teach students to recognize the value in each patient encounter, because each offers a unique opportunity to deepen their understanding of psychiatric conditions.⁴ Instead of being mere observers, students should actively participate in their education by involving themselves in clinical discussions, treatment planning, and decision-making.

The environment

A supportive, inclusive learning environment should foster diversity, inclusivity, and collaborative learning by creating an engaging atmosphere in which students can express themselves. In my experience, a sense of relaxed focus can help alleviate stress and enhance creativity. Emphasize a patient-centered approach to instill empathy and compassion in students and enrich their understanding of psychiatric conditions.⁴

The peers

Encourage students to engage in peer feedback, which will provide their fellow trainees additional perspective on their performance and offer an avenue for constructive criticism and improvement.³ Promoting collaborative learning will foster a sense of camaraderie, help students share their diverse perspectives, and enhance the learning experience. Peers also play a crucial role in reinforcing positive behaviors and attitudes.

My extensive experience educating medical students studying psychiatry in a busy ED has taught me that creating an exceptional learning environment requires understanding the role of educators, students, the environment, and peers. By implementing these principles, educators can contribute to their students’ professional growth, equipping them with the skills and mindset necessary to become a compassionate, competent, effective physician.

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

I was disheartened with the June 2023 issue of Current Psychiatry. This issue included “Optimizing benzodiazepine treatment of anxiety disorders” (p. 22-33,39, doi:10.12788/cp.0365). While these medications may be helpful for short-term treatment, I find their irresponsible use to be a much greater problem than their underutilization.¹

The benzodiazepine pharmacology discussed in this article is interesting, but it would be helpful if it had been integrated within a much more extensive discussion of careful prescribing practices. In 2020, the FDA updated the boxed warning to alert prescribers to the serious risks of abuse, addiction, physical dependence, and withdrawal reactions associated with benzodiazepines.² I would hope that an article on benzodiazepines would provide more discussion and guidance surrounding these important issues.

The June 2023 issue also included “High-dose stimulants for adult ADHD” (p. 34-39, doi:10.12788/cp.0366). This article provided esoteric advice on managing stimulant therapy in the setting of Roux-en-Y gastric bypass surgery, yet I would regard stimulant misuse as a far more common and pressing issue.^3,4 The recent Drug Enforcement Administration investigation of telehealth stimulant prescribing is a notable example of this problem.⁵

The patient discussed in this article was receiving large doses of stimulants for a purported case of refractory attention-deficit/hyperactivity disorder (ADHD). The article provided a sparse differential diagnosis for the patient’s intractable symptoms. While rapid metabolism may be an explanation, I would also like to know how the authors ruled out physiological dependence and/or addiction to a controlled substance. How was misuse excluded? Was urine drug testing (UDS) performed? UDS is highly irregular among prescribers,⁶ which suggests that practices for detecting covert substance abuse and stimulant misuse are inadequate. Wouldn’t such investigations be fundamental to ethical stimulant prescribing?

Jeff Sanders, MD, PhD
Atlanta, Georgia

References

1. Centers for Disease Control and Prevention. Trends in nonfatal and fatal overdoses involving benzodiazepines—38 states and the District of Columbia, 2019-2020. Accessed August 9, 2023. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a2.htm

2. US Food & Drug Administration. FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. Accessed August 14, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

3. McCabe SE, Schulenberg JE, Wilens TE, et al. Prescription stimulant medical and nonmedical use among US secondary school students, 2005 to 2020. JAMA Netw Open. 2023;6(4):e238707. doi:10.1001/jamanetworkopen.2023.8707

4. US Food & Drug Administration. FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions. Accessed August 14, 2023. https://www.fda.gov/safety/medical-product-safety-information/fda-updating-warnings-improve-safe-use-prescription-stimulants-used-treat-adhd-and-other-conditions

5. Vaidya A. Report: telehealth company’s prescribing practices come under DEA scrutiny. September 16, 2022. Accessed August 9, 2023. https://mhealthintelligence.com/news/report-telehealth-company-dones-prescribing-practices-come-under-dea-scrutiny

6. Zionts A. Some ADHD patients are drug-tested often, while others are never asked. Kaiser Health News. March 25, 2023. Accessed August 9, 2023. https://www.nbcnews.com/news/amp/rcna76330

Continue to: Drs. Stimpfl and Strawn respond

We thank Dr. Sanders for highlighting the need for clinical equipoise in considering the risks and benefits of medications—something that is true for benzodiazepines, antipsychotics, antidepressants, and in fact all medications. He reminds us that the risks of misuse, dependence, and withdrawal associated with benzodiazepines led to a boxed warning in September 2020 and highlights recent trends of fatal and nonfatal benzodiazepine overdose, especially when combined with opiates.

Our article, which aimed to educate clinicians on benzodiazepine pharma­cology and patient-specific factors influencing benzodiazepine selection and dosing, did not focus significantly on the risks associated with benzodiazepines. We do encourage careful and individualized benzodiazepine prescribing. However, we wish to remind our colleagues that benzodiazepines, while associated with risks, continue to have utility in acute and periprocedural settings, and remain an important treatment option for patients with panic disorder, generalized anxiety disorder (especially while waiting for other medications to take effect), catatonia, seizure disorders, and alcohol withdrawal.

We agree that patient-specific risk assessment is essential, as some patients benefit from benzodiazepines despite the risks. However, we also acknowledge that some individuals are at higher risk for adverse outcomes, including those with concurrent opiate use or who are prescribed other sedative-hypnotics; older adults and those with neurocognitive disorders; and patients susceptible to respiratory depression due to other medical reasons (eg, myasthenia gravis, sleep apnea, and chronic obstructive pulmonary disease). Further, we agree that benzodiazepine use during pregnancy is generally not advised due to the risks of neonatal hypotonia and neonatal withdrawal syndrome¹ as well as a possible risk of cleft palate that has been reported in some studies.² Finally, paradoxical reactions may be more common at the extremes of age and in patients with intellectual disability or personality disorders.^3,4

Patient characteristics that have been associated with a higher risk of benzodiazepine use disorder include lower education/income, unemployment, having another substance use disorder, and severe psychopathology.⁵ In some studies, using benzodiazepines for prolonged periods at high doses as well as using those with a rapid onset of action was associated with an increased risk of benzodiazepine use disorder.^5-7

Ultimately, we concur with Dr. Sanders on the perils of the “irresponsible use” of medication and emphasize the need for discernment when choosing treatments to avoid rashly discarding an effective remedy while attempting to mitigate all conceivable risks.

Julia Stimpfl, MD
Jeffrey R. Strawn, MD
Cincinnati, Ohio

References

1. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994;8(6):461-475. doi:10.1016/0890-6238(94)90029-9

2. Enato E, Moretti M, Koren G. The fetal safety of benzodiazepines: an updated meta-analysis. J Obstet Gynaecol Can. 2011;33(1):46-48. doi:10.1016/S1701-2163(16)34772-7 Erratum in: J Obstet Gynaecol Can. 2011;33(4):319.

3. Hakimi Y, Petitpain N, Pinzani V, et al. Paradoxical adverse drug reactions: descriptive analysis of French reports. Eur J Clin Pharmacol. 2020;76(8):1169-1174. doi:10.1007/s00228-020-02892-2

4. Paton C. Benzodiazepines and disinhibition: a review. Psychiatric Bulletin. 2002;26(12):460-462. doi:10.1192/pb.26.12.460

5. Fride Tvete I, Bjørner T, Skomedal T. Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway. Scand J Prim Health Care. 2015;33(4):252-259. doi:10.3109/02813432.2015.1117282

6. Griffiths RR, Johnson MW. Relative abuse liability of hypnotic drugs: a conceptual framework and algorithm for differentiating among compounds. J Clin Psychiatry. 2005;66 Suppl 9:31-41.

7. Kan CC, Hilberink SR, Breteler MH. Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach. Compr Psychiatry. 2004;45(2):88-94. doi:10.1016/j.comppsych.2003.12.007

Continue to: Drs. Sarma and Grady respond

Dr. Sanders’ letter highlights the potential caveats associated with prescribing controlled substances. We agree that our short case summary includes numerous interesting elements, each of which would be worthy of further exploration and discussion. Our choice was to highlight the patient history of bariatric surgery and use this as a springboard into a review of stimulants, including the newest formulations for ADHD. For more than 1 year, many generic stimulants have been in short supply, and patients and clinicians have been seeking other therapeutic options. Given this background and with newer, branded stimulant use becoming more commonplace, we believe our article was useful and timely.

Our original intent had been to include an example of a controlled substance agreement. Regrettably, there was simply not enough space for this document or the additional discussion that its inclusion would deem necessary. Nevertheless, had the May 2023 FDA requirement for manufacturers to update the labeling of prescription stimulants¹ to clarify misuse and abuse been published before our article’s final revision, we would have mentioned it and provided the appropriate link.

Subbu J. Sarma, MD, FAPA
Kansas City, Missouri

Sarah E. Grady, PharmD, BCPS, BCPP
Des Moines, Iowa

References

1. US Food & Drug Administration. FDA requires updates to clarify labeling of prescription stimulants used to treat ADHD and other conditions. Accessed August 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-updates-clarify-labeling-prescription-stimulants-used-treat-adhd-and-other-conditions

Off-label prescribing (OLP) refers to the practice of using medications for indications outside of those approved by the FDA, or in dosages, dose forms, or patient populations that have not been approved by the FDA.¹ OLP is common, occurring in many practice settings and nearly every medical specialty. In a 2006 review, Radley et al² found OLP accounted for 21% of the overall use of 160 common medications. The frequency of OLP varies between medication classes. Off-label use of anticonvulsants, antidepressants, and antipsychotics tends to be higher than that of other medications.^3,4 OLP is often more common in patient populations unlikely to be included in clinical trials due to ethical or logistical difficulties, such as pediatric patients and individuals who are pregnant. The Box summarizes several components that contribute to the prevalence of OLP and explains why this practice is often necessary for treating certain substance-related and addictive disorders.

Box

Several important medicolegal and ethical considerations surround OLP. The FDA prohibits off-label promotion, in which manufacturers advertise the use of a medication for off-label use.⁵ However, regulations allow physicians to use their best clinical judgment when prescribing medications for off-label use. When considering off-label use of any medication, physicians should review the most up-to-date research, including clinical trials, case reports, and reviews to safely support their decision-making. OLP should be guided by ethical principles such as autonomy, beneficence, nonmaleficence, and justice. Physicians should obtain informed consent by conducting an appropriate discussion of the risks, benefits, and alternatives of off-label medications. This conversation should be clearly documented, and physicians should provide written material regarding off-label options to patients when available. Finally, physicians should verify their patients’ understanding of this discussion, and allow patients to accept or decline off-label medications without pressure.

This article focuses on current and potential future medications available for OLP to treat patients with alcohol use disorder (AUD), gambling disorder (GD), stimulant use disorder, and cannabis use disorder.

Alcohol use disorder

CASE 1

Ms. X, age 67, has a history of severe AUD, mild renal impairment, and migraines. She presents to the outpatient clinic seeking help to drink less alcohol. Ms. X reports drinking 1 to 2 bottles of wine each day. She was previously treated for AUD but was not helped by naltrexone and did not tolerate disulfiram (abstinence was not her goal and she experienced significant adverse effects). Ms. X says she has a medical history of chronic migraines but denies other medical issues. The treatment team discusses alternative pharmacologic options, including acamprosate and topiramate. After outlining the dosing schedule and risks/benefits with Ms. X, you make the joint decision to start topiramate to reduce alcohol cravings and target her migraine symptoms.

Only 3 medications are FDA-approved for treating AUD: disulfiram, naltrexone (oral and injectable formulations), and acamprosate. Off-label options for AUD treatment include gabapentin, topiramate, and baclofen.

Gabapentin is FDA-approved for treating postherpetic neuralgia and partial seizures in patients age ≥3. The exact mechanism of action is unclear, though its effects are possibly related to its activity as a calcium channel ligand. It also carries a structural resemblance to gamma-aminobutyric acid (GABA), though it lacks activity at GABA receptors.

Several randomized controlled trials (RCTs) evaluating the efficacy of gabapentin for AUD produced promising results. In a comparison of gabapentin vs placebo for AUD, Anton et al⁶ found gabapentin led to significant increases in the number of participants with total alcohol abstinence and participants who reported reduced drinking. Notably, the effect was most prominent in those with heavy drinking patterns and pretreatment alcohol withdrawal symptoms. A total of 41% of participants with high alcohol withdrawal scores on pretreatment evaluation achieved total abstinence while taking gabapentin, compared to 1% in the placebo group.⁶ A meta-analysis of gabapentin for AUD by Kranzler et al⁷ included 7 RCTs and 32 effect measures. It found that although all outcome measures favored gabapentin over placebo, only the percentage of heavy drinking days was significantly different.

Gabapentin is dosed between 300 to 600 mg 3 times per day, but 1 study found that a higher dose (1,800 mg/d) was associated with better outcomes.⁸ Common adverse effects include sedation, dizziness, peripheral edema, and ataxia.

Continue to: Topiramate

Topiramate blocks voltage-gated sodium channels and enhances GABA-A receptor activity.⁹ It is indicated for the treatment of seizures, migraine prophylaxis, weight management, and weight loss. Several clinical trials, including RCTs,^10-12 demonstrated that topiramate was superior to placebo in reducing the percentage of heavy drinking days and overall drinking days. Some also showed that topiramate was associated with abstinence and reduced craving levels.^12,13 A meta-analysis by Blodgett et al¹⁴ found that compared to placebo, topiramate lowered the rate of heavy drinking and increased abstinence.

Topiramate is dosed from 50 to 150 mg twice daily, although some studies suggest a lower dose (≤75 mg/d) may be associated with clinical benefits.^15,16 One important clinical consideration: topiramate must follow a slow titration schedule (4 to 6 weeks) to increase tolerability and avoid adverse effects. Common adverse effects include sedation, word-finding difficulty, paresthesia, increased risk for renal calculi, dizziness, anorexia, and alterations in taste.

Baclofen is a GABA-B agonist FDA-approved for the treatment of muscle spasticity related to multiple sclerosis and reversible spasticity related to spinal cord lesions and multiple sclerosis. Of note, it is approved for treatment of AUD in Europe.

In a meta-analysis of 13 RCTs, Pierce et al¹⁷ found a greater likelihood of abstinence and greater time to first lapse of drinking with baclofen compared to placebo. Interestingly, a subgroup analysis found that the positive effects were limited to trials that used 30 to 60 mg/d of baclofen, and not evident in those that used higher doses. Additionally, there was no difference between baclofen and placebo with regard to several important outcomes, including alcohol cravings, anxiety, depression, or number of total abstinent days. A review by Andrade¹⁸ proposed that individualized treatment with high-dose baclofen (30 to 300 mg/d) may be a useful second-line approach in heavy drinkers who wish to reduce their alcohol intake.

Continue to: Before starting baclofen...

Before starting baclofen, patients should be informed about its adverse effects. Common adverse effects include sedation and motor impairment. More serious but less common adverse effects include seizures, respiratory depression with sleep apnea, severe mood disorders (ie, mania, depression, or suicide risk), and mental confusion. Baclofen should be gradually discontinued, because there is some risk of clinical withdrawal symptoms (ie, agitation, confusion, seizures, or delirium).

Among the medications discussed in this section, the evidence for gabapentin and topiramate is moderate to strong, while the evidence for baclofen is overall weaker or mixed. The American Psychiatric Association’s Practice Guideline suggests offering gabapentin or topiramate to patients with moderate to severe AUD whose goal is to achieve abstinence or reduce alcohol use, or those who prefer gabapentin or topiramate or cannot tolerate or have not responded to naltrexone and acamprosate.¹⁹ Clinicians must ensure patients have no contra­indications to the use of these medications. Due to the moderate quality evidence for a significant reduction in heavy drinking and increased abstinence,^14,20 a practice guideline from the US Department of Veterans Affairs and US Department of Defense²¹ recommends topiramate as 1 of 2 first-line treatments (the other is naltrexone). This guideline suggests gabapentin as a second-line treatment for AUD.²¹

Gambling disorder

CASE 2

Mr. P, age 28, seeks treatment for GD and cocaine use disorder. He reports a 7-year history of sports betting that has increasingly impaired his functioning over the past year. He lost his job, savings, and familial relationships due to his impulsive and risky behavior. Mr. P also reports frequent cocaine use, about 2 to 3 days per week, mostly on the weekends. The psychiatrist tells Mr. P there is no FDA-approved pharmacologic treatment for GD or cocaine use disorder. The psychiatrist discusses the option of naltrexone as off-label treatment for GD with the goal of reducing Mr. P’s urges to gamble, and points to possible benefits for cocaine use disorder.

GD impacts approximately 0.5% of the adult US population and is often co-occurring with substance use disorders.²² It is thought to share neurobiological and clinical similarities with substance use disorders.²³ There are currently no FDA-approved medications to treat the disorder. In studies of GD, treatment success with antidepressants and mood stabilizers has not been consistent,^23,24 but some promising results have been published for the opioid receptor antagonist naltrexone^24-29and N-acetylcysteine (NAC).^30-32

Naltrexone is thought to reduce gambling behavior and urges via downstream modulation of mesolimbic dopamine circuitry.²⁴ It is FDA-approved for the treatment of AUD and opioid use disorder. Open-label RCTs have found a reduction in gambling urges and behavior with daily naltrexone.^25-27 Dosing at 50 mg/d appears to be just as efficacious as higher doses such as 100 and 150 mg/d.²⁷ When used as a daily as-needed medication for strong gambling urges or if an individual was planning to gamble, naltrexone 50 mg/d was not effective.²⁸

Continue to: Naltrexone typically is started...

Naltrexone typically is started at 25 mg/d to assess tolerability and quickly titrated to 50 mg/d. When titrating, common adverse effects include nausea, vomiting, and transient elevations in transaminases. Another opioid antagonist, nalmefene, has also been studied in patients with GD. An RCT by Grant et al²⁹ that evaluated 207 patients found that compared with placebo, nalmefene 25 mg/d for 16 weeks was associated with a significant reduction in gambling assessment scores. In Europe, nalmefene is approved for treating AUD but the oral formulation is not currently available in the US.

N-acetylcysteine is thought to potentially reverse neuronal dysfunction seen in addictive disorders by glutamatergic modulation.³⁰ Research investigating NAC for GD is scarce. A pilot study found 16 of 27 patients with GD reduced gambling behavior with a mean dose of 1,476.9 mg/d.³¹ An additional study investigating the addition of NAC to behavioral therapy in nicotine-dependent individuals with pathologic gambling found a reduction in problem gambling after 18 weeks (6 weeks + 3 months follow-up).³² Common but mild adverse effects associated with NAC are nausea, vomiting, and diarrhea.

A meta-analysis by Goslar et al³³ that reviewed 34 studies (1,340 participants) found pharmacologic treatments were associated with large and medium pre-post reductions in global severity, frequency, and financial loss in patients with GD. RCTs studying opioid antagonists and mood stabilizers (combined with a cognitive intervention) as well as lithium for patients with comorbid bipolar disorder and GD demonstrated promising results.³³

Stimulant use disorder

There are no FDA-approved medications for stimulant use disorder. Multiple off-label options have been studied for the treatment of methamphetamine abuse and cocaine abuse.

Methamphetamine use has been expanding over the past decade with a 3.6-fold increase in positive methamphetamine screens in overdose deaths from 2011 to 2016.³⁴ Pharmacologic options studied for OLP of methamphetamine use disorder include mirtazapine, bupropion, naltrexone, and topiramate.

Continue to: Mirtazapine

Mirtazapine is an atypical antidepressant whose mechanism of action includes modulation of the serotonin, norepinephrine, and alpha-2 adrenergic systems. It is FDA-approved for the treatment of major depressive disorder (MDD). In a randomized placebo-controlled study, mirtazapine 30 mg/d at night was found to decrease methamphetamine use for active users and led to decreased sexual risk in men who have sex with men.³⁵ These results were supported by an additional RCT in which mirtazapine 30 mg/d significantly reduced rates of methamphetamine use vs placebo at 24 and 36 weeks despite poor medication adherence.³⁶ Adverse effects to monitor in patients treated with mirtazapine include increased appetite, weight gain, sedation, and constipation.

Bupropion is a norepinephrine dopamine reuptake inhibitor that produces increased neurotransmission of norepinephrine and dopamine in the CNS. It is FDA-approved for the treatment of MDD and as an aid for smoking cessation. Bupropion has been studied for methamphetamine use disorder with mixed results. In a randomized placebo-controlled trial, bupropion sustained release 150 mg twice daily was not more effective than placebo in reducing methamphetamine use.³⁷ However, the extended-release formulation of bupropion 450 mg/d combined with long-acting injectable naltrexone was associated with a reduction in methamphetamine use over 12 weeks.³⁸ Bupropion is generally well tolerated; common adverse effects include insomnia, tremor, headache, and dizziness.

Naltrexone. Data about using oral naltrexone to treat stimulant use disorders are limited. A randomized, placebo-controlled trial by Jayaram-Lindström et al³⁹ found naltrexone 50 mg/d significantly reduced amphetamine use compared to placebo. Additionally, naltrexone 50 and 150 mg/d have been shown to reduce cocaine use over time in combination with therapy for cocaine-dependent patients and those dependent on alcohol and cocaine.^40,41

Topiramate has been studied for the treatment of cocaine use disorder. It is hypothesized that modulation of the mesocorticolimbic dopamine system may contribute to decreased cocaine cravings.⁴² A pilot study by Kampman et al⁴³ found that after an 8-week titration of topiramate to 200 mg/d, individuals were more likely to achieve cocaine abstinence compared to those who receive placebo. In an RCT, Elkashef et al⁴⁴ did not find topiramate assisted with increased abstinence of methamphetamine in active users at a target dose of 200 mg/d. However, it was associated with reduced relapse rates in individuals who were abstinent prior to the study.⁴⁴ At a target dose of 300 mg/d, topiramate also outperformed placebo in decreasing days of cocaine use.⁴² Adverse effects of topiramate included paresthesia, alteration in taste, and difficulty with concentration.

Cannabis use disorder

In recent years, cannabis use in the US has greatly increased⁴⁵ but no medications are FDA-approved for treating cannabis use disorder. Studies of pharmacologic options for cannabis use disorder have had mixed results.⁴⁶ A meta-analysis by Bahji et al⁴⁷ of 24 studies investigating pharmacotherapies for cannabis use disorder highlighted the lack of adequate evidence. In this section, we focus on a few positive trials of NAC and gabapentin.

Continue to: N-acetylcysteine

N-acetylcysteine. Studies investigating NAC 1,200 mg twice daily have been promising in adolescent and adult populations.^48-50 There are some mixed results, however. A large RCT found NAC 1,200 mg twice daily was not better than placebo in helping adults achieve abstinence from cannabis.⁵¹

Gabapentin may be a viable option for treating cannabis use disorder. A pilot study by Mason et al⁵² found gabapentin 1,200 mg/d was more effective than placebo at reducing cannabis use among treatment-seeking adults.

When and how to consider OLP

OLP for addictive disorders is common and often necessary. This is primarily due to limitations of the FDA-approved medications and because there are no FDA-approved medications for many substance-related and addictive disorders (ie, GD, cannabis use disorder, and stimulant use disorder). When assessing pharmacotherapy options, if FDA-approved medications are available for certain diagnoses, clinicians should first consider them. The off-label medications discussed in this article are outlined in the Table.^{6-21,24-28,30-33,35-44,48-52}

The overall level of evidence to support the use of off-label medications is lower than that of FDA-approved medications, which contributes to potential medicolegal concerns of OLP. Off-label medications should be considered when there are no FDA-approved medications available, and the decision to use off-label medications should be based on evidence from the literature and current standard of care. Additionally, OLP is necessary if a patient cannot tolerate FDA-approved medications, is not helped by FDA-approved treatments, or when there are other clinical reasons to choose a particular off-label medication. For example, if a patient has comorbid AUD and obesity (or migraines), using topiramate may be appropriate because it may target alcohol cravings and can be helpful for weight loss (and migraine prophylaxis). Similarly, for patients with AUD and neuropathic pain, using gabapentin can be considered for its dual therapeutic effects.

It is critical for clinicians to understand the landscape of off-label options for treating addictive disorders. Additional research in the form of RCTs is needed to better clarify the efficacy and adverse effects of these treatments.

Continue to: Bottom Line

Off-label prescribing is prevalent in practice, including in the treatment of substance-related and addictive disorders. When considering off-label use of any medication, clinicians should review the most recent research, obtain informed consent from patients, and verify patients’ understanding of the potential risks and adverse effects associated with the particular medication.

Related Resources

• Joshi KG, Frierson RL. Off-label prescribing: how to limit your liability. Current Psychiatry. 2020;19(9):12,39. doi:10.12788/ cp.0035
• Stanciu CN, Gnanasegaram SA. Don’t balk at using medical therapy to manage alcohol use disorder. Current Psychiatry. 2017;16(2):50-52.

Drug Brand Names

Acamprosate • Campral
Baclofen • Ozobax
Bupropion • Wellbutrin, Zyban
Disulfiram • Antabuse
Gabapentin • Neurontin
Lithium • Eskalith, Lithobid
Mirtazapine • Remeron
Naltrexone • ReVia, Vivitrol
Topiramate • Topamax

Off-label prescribing (OLP) refers to the practice of using medications for indications outside of those approved by the FDA, or in dosages, dose forms, or patient populations that have not been approved by the FDA.¹ OLP is common, occurring in many practice settings and nearly every medical specialty. In a 2006 review, Radley et al² found OLP accounted for 21% of the overall use of 160 common medications. The frequency of OLP varies between medication classes. Off-label use of anticonvulsants, antidepressants, and antipsychotics tends to be higher than that of other medications.^3,4 OLP is often more common in patient populations unlikely to be included in clinical trials due to ethical or logistical difficulties, such as pediatric patients and individuals who are pregnant. The Box summarizes several components that contribute to the prevalence of OLP and explains why this practice is often necessary for treating certain substance-related and addictive disorders.

Box

Several important medicolegal and ethical considerations surround OLP. The FDA prohibits off-label promotion, in which manufacturers advertise the use of a medication for off-label use.⁵ However, regulations allow physicians to use their best clinical judgment when prescribing medications for off-label use. When considering off-label use of any medication, physicians should review the most up-to-date research, including clinical trials, case reports, and reviews to safely support their decision-making. OLP should be guided by ethical principles such as autonomy, beneficence, nonmaleficence, and justice. Physicians should obtain informed consent by conducting an appropriate discussion of the risks, benefits, and alternatives of off-label medications. This conversation should be clearly documented, and physicians should provide written material regarding off-label options to patients when available. Finally, physicians should verify their patients’ understanding of this discussion, and allow patients to accept or decline off-label medications without pressure.

This article focuses on current and potential future medications available for OLP to treat patients with alcohol use disorder (AUD), gambling disorder (GD), stimulant use disorder, and cannabis use disorder.

Alcohol use disorder

CASE 1

Ms. X, age 67, has a history of severe AUD, mild renal impairment, and migraines. She presents to the outpatient clinic seeking help to drink less alcohol. Ms. X reports drinking 1 to 2 bottles of wine each day. She was previously treated for AUD but was not helped by naltrexone and did not tolerate disulfiram (abstinence was not her goal and she experienced significant adverse effects). Ms. X says she has a medical history of chronic migraines but denies other medical issues. The treatment team discusses alternative pharmacologic options, including acamprosate and topiramate. After outlining the dosing schedule and risks/benefits with Ms. X, you make the joint decision to start topiramate to reduce alcohol cravings and target her migraine symptoms.

Only 3 medications are FDA-approved for treating AUD: disulfiram, naltrexone (oral and injectable formulations), and acamprosate. Off-label options for AUD treatment include gabapentin, topiramate, and baclofen.

Gabapentin is FDA-approved for treating postherpetic neuralgia and partial seizures in patients age ≥3. The exact mechanism of action is unclear, though its effects are possibly related to its activity as a calcium channel ligand. It also carries a structural resemblance to gamma-aminobutyric acid (GABA), though it lacks activity at GABA receptors.

Several randomized controlled trials (RCTs) evaluating the efficacy of gabapentin for AUD produced promising results. In a comparison of gabapentin vs placebo for AUD, Anton et al⁶ found gabapentin led to significant increases in the number of participants with total alcohol abstinence and participants who reported reduced drinking. Notably, the effect was most prominent in those with heavy drinking patterns and pretreatment alcohol withdrawal symptoms. A total of 41% of participants with high alcohol withdrawal scores on pretreatment evaluation achieved total abstinence while taking gabapentin, compared to 1% in the placebo group.⁶ A meta-analysis of gabapentin for AUD by Kranzler et al⁷ included 7 RCTs and 32 effect measures. It found that although all outcome measures favored gabapentin over placebo, only the percentage of heavy drinking days was significantly different.

Gabapentin is dosed between 300 to 600 mg 3 times per day, but 1 study found that a higher dose (1,800 mg/d) was associated with better outcomes.⁸ Common adverse effects include sedation, dizziness, peripheral edema, and ataxia.

Continue to: Topiramate

Topiramate blocks voltage-gated sodium channels and enhances GABA-A receptor activity.⁹ It is indicated for the treatment of seizures, migraine prophylaxis, weight management, and weight loss. Several clinical trials, including RCTs,^10-12 demonstrated that topiramate was superior to placebo in reducing the percentage of heavy drinking days and overall drinking days. Some also showed that topiramate was associated with abstinence and reduced craving levels.^12,13 A meta-analysis by Blodgett et al¹⁴ found that compared to placebo, topiramate lowered the rate of heavy drinking and increased abstinence.

Topiramate is dosed from 50 to 150 mg twice daily, although some studies suggest a lower dose (≤75 mg/d) may be associated with clinical benefits.^15,16 One important clinical consideration: topiramate must follow a slow titration schedule (4 to 6 weeks) to increase tolerability and avoid adverse effects. Common adverse effects include sedation, word-finding difficulty, paresthesia, increased risk for renal calculi, dizziness, anorexia, and alterations in taste.

Baclofen is a GABA-B agonist FDA-approved for the treatment of muscle spasticity related to multiple sclerosis and reversible spasticity related to spinal cord lesions and multiple sclerosis. Of note, it is approved for treatment of AUD in Europe.

In a meta-analysis of 13 RCTs, Pierce et al¹⁷ found a greater likelihood of abstinence and greater time to first lapse of drinking with baclofen compared to placebo. Interestingly, a subgroup analysis found that the positive effects were limited to trials that used 30 to 60 mg/d of baclofen, and not evident in those that used higher doses. Additionally, there was no difference between baclofen and placebo with regard to several important outcomes, including alcohol cravings, anxiety, depression, or number of total abstinent days. A review by Andrade¹⁸ proposed that individualized treatment with high-dose baclofen (30 to 300 mg/d) may be a useful second-line approach in heavy drinkers who wish to reduce their alcohol intake.

Continue to: Before starting baclofen...

Before starting baclofen, patients should be informed about its adverse effects. Common adverse effects include sedation and motor impairment. More serious but less common adverse effects include seizures, respiratory depression with sleep apnea, severe mood disorders (ie, mania, depression, or suicide risk), and mental confusion. Baclofen should be gradually discontinued, because there is some risk of clinical withdrawal symptoms (ie, agitation, confusion, seizures, or delirium).

Among the medications discussed in this section, the evidence for gabapentin and topiramate is moderate to strong, while the evidence for baclofen is overall weaker or mixed. The American Psychiatric Association’s Practice Guideline suggests offering gabapentin or topiramate to patients with moderate to severe AUD whose goal is to achieve abstinence or reduce alcohol use, or those who prefer gabapentin or topiramate or cannot tolerate or have not responded to naltrexone and acamprosate.¹⁹ Clinicians must ensure patients have no contra­indications to the use of these medications. Due to the moderate quality evidence for a significant reduction in heavy drinking and increased abstinence,^14,20 a practice guideline from the US Department of Veterans Affairs and US Department of Defense²¹ recommends topiramate as 1 of 2 first-line treatments (the other is naltrexone). This guideline suggests gabapentin as a second-line treatment for AUD.²¹

Gambling disorder

CASE 2

Mr. P, age 28, seeks treatment for GD and cocaine use disorder. He reports a 7-year history of sports betting that has increasingly impaired his functioning over the past year. He lost his job, savings, and familial relationships due to his impulsive and risky behavior. Mr. P also reports frequent cocaine use, about 2 to 3 days per week, mostly on the weekends. The psychiatrist tells Mr. P there is no FDA-approved pharmacologic treatment for GD or cocaine use disorder. The psychiatrist discusses the option of naltrexone as off-label treatment for GD with the goal of reducing Mr. P’s urges to gamble, and points to possible benefits for cocaine use disorder.

GD impacts approximately 0.5% of the adult US population and is often co-occurring with substance use disorders.²² It is thought to share neurobiological and clinical similarities with substance use disorders.²³ There are currently no FDA-approved medications to treat the disorder. In studies of GD, treatment success with antidepressants and mood stabilizers has not been consistent,^23,24 but some promising results have been published for the opioid receptor antagonist naltrexone^24-29and N-acetylcysteine (NAC).^30-32

Naltrexone is thought to reduce gambling behavior and urges via downstream modulation of mesolimbic dopamine circuitry.²⁴ It is FDA-approved for the treatment of AUD and opioid use disorder. Open-label RCTs have found a reduction in gambling urges and behavior with daily naltrexone.^25-27 Dosing at 50 mg/d appears to be just as efficacious as higher doses such as 100 and 150 mg/d.²⁷ When used as a daily as-needed medication for strong gambling urges or if an individual was planning to gamble, naltrexone 50 mg/d was not effective.²⁸

Continue to: Naltrexone typically is started...

Naltrexone typically is started at 25 mg/d to assess tolerability and quickly titrated to 50 mg/d. When titrating, common adverse effects include nausea, vomiting, and transient elevations in transaminases. Another opioid antagonist, nalmefene, has also been studied in patients with GD. An RCT by Grant et al²⁹ that evaluated 207 patients found that compared with placebo, nalmefene 25 mg/d for 16 weeks was associated with a significant reduction in gambling assessment scores. In Europe, nalmefene is approved for treating AUD but the oral formulation is not currently available in the US.

N-acetylcysteine is thought to potentially reverse neuronal dysfunction seen in addictive disorders by glutamatergic modulation.³⁰ Research investigating NAC for GD is scarce. A pilot study found 16 of 27 patients with GD reduced gambling behavior with a mean dose of 1,476.9 mg/d.³¹ An additional study investigating the addition of NAC to behavioral therapy in nicotine-dependent individuals with pathologic gambling found a reduction in problem gambling after 18 weeks (6 weeks + 3 months follow-up).³² Common but mild adverse effects associated with NAC are nausea, vomiting, and diarrhea.

A meta-analysis by Goslar et al³³ that reviewed 34 studies (1,340 participants) found pharmacologic treatments were associated with large and medium pre-post reductions in global severity, frequency, and financial loss in patients with GD. RCTs studying opioid antagonists and mood stabilizers (combined with a cognitive intervention) as well as lithium for patients with comorbid bipolar disorder and GD demonstrated promising results.³³

Stimulant use disorder

There are no FDA-approved medications for stimulant use disorder. Multiple off-label options have been studied for the treatment of methamphetamine abuse and cocaine abuse.

Methamphetamine use has been expanding over the past decade with a 3.6-fold increase in positive methamphetamine screens in overdose deaths from 2011 to 2016.³⁴ Pharmacologic options studied for OLP of methamphetamine use disorder include mirtazapine, bupropion, naltrexone, and topiramate.

Continue to: Mirtazapine

Mirtazapine is an atypical antidepressant whose mechanism of action includes modulation of the serotonin, norepinephrine, and alpha-2 adrenergic systems. It is FDA-approved for the treatment of major depressive disorder (MDD). In a randomized placebo-controlled study, mirtazapine 30 mg/d at night was found to decrease methamphetamine use for active users and led to decreased sexual risk in men who have sex with men.³⁵ These results were supported by an additional RCT in which mirtazapine 30 mg/d significantly reduced rates of methamphetamine use vs placebo at 24 and 36 weeks despite poor medication adherence.³⁶ Adverse effects to monitor in patients treated with mirtazapine include increased appetite, weight gain, sedation, and constipation.

Bupropion is a norepinephrine dopamine reuptake inhibitor that produces increased neurotransmission of norepinephrine and dopamine in the CNS. It is FDA-approved for the treatment of MDD and as an aid for smoking cessation. Bupropion has been studied for methamphetamine use disorder with mixed results. In a randomized placebo-controlled trial, bupropion sustained release 150 mg twice daily was not more effective than placebo in reducing methamphetamine use.³⁷ However, the extended-release formulation of bupropion 450 mg/d combined with long-acting injectable naltrexone was associated with a reduction in methamphetamine use over 12 weeks.³⁸ Bupropion is generally well tolerated; common adverse effects include insomnia, tremor, headache, and dizziness.

Naltrexone. Data about using oral naltrexone to treat stimulant use disorders are limited. A randomized, placebo-controlled trial by Jayaram-Lindström et al³⁹ found naltrexone 50 mg/d significantly reduced amphetamine use compared to placebo. Additionally, naltrexone 50 and 150 mg/d have been shown to reduce cocaine use over time in combination with therapy for cocaine-dependent patients and those dependent on alcohol and cocaine.^40,41

Topiramate has been studied for the treatment of cocaine use disorder. It is hypothesized that modulation of the mesocorticolimbic dopamine system may contribute to decreased cocaine cravings.⁴² A pilot study by Kampman et al⁴³ found that after an 8-week titration of topiramate to 200 mg/d, individuals were more likely to achieve cocaine abstinence compared to those who receive placebo. In an RCT, Elkashef et al⁴⁴ did not find topiramate assisted with increased abstinence of methamphetamine in active users at a target dose of 200 mg/d. However, it was associated with reduced relapse rates in individuals who were abstinent prior to the study.⁴⁴ At a target dose of 300 mg/d, topiramate also outperformed placebo in decreasing days of cocaine use.⁴² Adverse effects of topiramate included paresthesia, alteration in taste, and difficulty with concentration.

Cannabis use disorder

In recent years, cannabis use in the US has greatly increased⁴⁵ but no medications are FDA-approved for treating cannabis use disorder. Studies of pharmacologic options for cannabis use disorder have had mixed results.⁴⁶ A meta-analysis by Bahji et al⁴⁷ of 24 studies investigating pharmacotherapies for cannabis use disorder highlighted the lack of adequate evidence. In this section, we focus on a few positive trials of NAC and gabapentin.

Continue to: N-acetylcysteine

N-acetylcysteine. Studies investigating NAC 1,200 mg twice daily have been promising in adolescent and adult populations.^48-50 There are some mixed results, however. A large RCT found NAC 1,200 mg twice daily was not better than placebo in helping adults achieve abstinence from cannabis.⁵¹

Gabapentin may be a viable option for treating cannabis use disorder. A pilot study by Mason et al⁵² found gabapentin 1,200 mg/d was more effective than placebo at reducing cannabis use among treatment-seeking adults.

When and how to consider OLP

OLP for addictive disorders is common and often necessary. This is primarily due to limitations of the FDA-approved medications and because there are no FDA-approved medications for many substance-related and addictive disorders (ie, GD, cannabis use disorder, and stimulant use disorder). When assessing pharmacotherapy options, if FDA-approved medications are available for certain diagnoses, clinicians should first consider them. The off-label medications discussed in this article are outlined in the Table.^{6-21,24-28,30-33,35-44,48-52}

The overall level of evidence to support the use of off-label medications is lower than that of FDA-approved medications, which contributes to potential medicolegal concerns of OLP. Off-label medications should be considered when there are no FDA-approved medications available, and the decision to use off-label medications should be based on evidence from the literature and current standard of care. Additionally, OLP is necessary if a patient cannot tolerate FDA-approved medications, is not helped by FDA-approved treatments, or when there are other clinical reasons to choose a particular off-label medication. For example, if a patient has comorbid AUD and obesity (or migraines), using topiramate may be appropriate because it may target alcohol cravings and can be helpful for weight loss (and migraine prophylaxis). Similarly, for patients with AUD and neuropathic pain, using gabapentin can be considered for its dual therapeutic effects.

It is critical for clinicians to understand the landscape of off-label options for treating addictive disorders. Additional research in the form of RCTs is needed to better clarify the efficacy and adverse effects of these treatments.

Continue to: Bottom Line

Off-label prescribing is prevalent in practice, including in the treatment of substance-related and addictive disorders. When considering off-label use of any medication, clinicians should review the most recent research, obtain informed consent from patients, and verify patients’ understanding of the potential risks and adverse effects associated with the particular medication.

Related Resources

• Joshi KG, Frierson RL. Off-label prescribing: how to limit your liability. Current Psychiatry. 2020;19(9):12,39. doi:10.12788/ cp.0035
• Stanciu CN, Gnanasegaram SA. Don’t balk at using medical therapy to manage alcohol use disorder. Current Psychiatry. 2017;16(2):50-52.

Drug Brand Names

Acamprosate • Campral
Baclofen • Ozobax
Bupropion • Wellbutrin, Zyban
Disulfiram • Antabuse
Gabapentin • Neurontin
Lithium • Eskalith, Lithobid
Mirtazapine • Remeron
Naltrexone • ReVia, Vivitrol
Topiramate • Topamax

Off-label prescribing (OLP) refers to the practice of using medications for indications outside of those approved by the FDA, or in dosages, dose forms, or patient populations that have not been approved by the FDA.¹ OLP is common, occurring in many practice settings and nearly every medical specialty. In a 2006 review, Radley et al² found OLP accounted for 21% of the overall use of 160 common medications. The frequency of OLP varies between medication classes. Off-label use of anticonvulsants, antidepressants, and antipsychotics tends to be higher than that of other medications.^3,4 OLP is often more common in patient populations unlikely to be included in clinical trials due to ethical or logistical difficulties, such as pediatric patients and individuals who are pregnant. The Box summarizes several components that contribute to the prevalence of OLP and explains why this practice is often necessary for treating certain substance-related and addictive disorders.

Box

Several important medicolegal and ethical considerations surround OLP. The FDA prohibits off-label promotion, in which manufacturers advertise the use of a medication for off-label use.⁵ However, regulations allow physicians to use their best clinical judgment when prescribing medications for off-label use. When considering off-label use of any medication, physicians should review the most up-to-date research, including clinical trials, case reports, and reviews to safely support their decision-making. OLP should be guided by ethical principles such as autonomy, beneficence, nonmaleficence, and justice. Physicians should obtain informed consent by conducting an appropriate discussion of the risks, benefits, and alternatives of off-label medications. This conversation should be clearly documented, and physicians should provide written material regarding off-label options to patients when available. Finally, physicians should verify their patients’ understanding of this discussion, and allow patients to accept or decline off-label medications without pressure.

This article focuses on current and potential future medications available for OLP to treat patients with alcohol use disorder (AUD), gambling disorder (GD), stimulant use disorder, and cannabis use disorder.

Alcohol use disorder

CASE 1

Ms. X, age 67, has a history of severe AUD, mild renal impairment, and migraines. She presents to the outpatient clinic seeking help to drink less alcohol. Ms. X reports drinking 1 to 2 bottles of wine each day. She was previously treated for AUD but was not helped by naltrexone and did not tolerate disulfiram (abstinence was not her goal and she experienced significant adverse effects). Ms. X says she has a medical history of chronic migraines but denies other medical issues. The treatment team discusses alternative pharmacologic options, including acamprosate and topiramate. After outlining the dosing schedule and risks/benefits with Ms. X, you make the joint decision to start topiramate to reduce alcohol cravings and target her migraine symptoms.

Only 3 medications are FDA-approved for treating AUD: disulfiram, naltrexone (oral and injectable formulations), and acamprosate. Off-label options for AUD treatment include gabapentin, topiramate, and baclofen.

Gabapentin is FDA-approved for treating postherpetic neuralgia and partial seizures in patients age ≥3. The exact mechanism of action is unclear, though its effects are possibly related to its activity as a calcium channel ligand. It also carries a structural resemblance to gamma-aminobutyric acid (GABA), though it lacks activity at GABA receptors.

Several randomized controlled trials (RCTs) evaluating the efficacy of gabapentin for AUD produced promising results. In a comparison of gabapentin vs placebo for AUD, Anton et al⁶ found gabapentin led to significant increases in the number of participants with total alcohol abstinence and participants who reported reduced drinking. Notably, the effect was most prominent in those with heavy drinking patterns and pretreatment alcohol withdrawal symptoms. A total of 41% of participants with high alcohol withdrawal scores on pretreatment evaluation achieved total abstinence while taking gabapentin, compared to 1% in the placebo group.⁶ A meta-analysis of gabapentin for AUD by Kranzler et al⁷ included 7 RCTs and 32 effect measures. It found that although all outcome measures favored gabapentin over placebo, only the percentage of heavy drinking days was significantly different.

Gabapentin is dosed between 300 to 600 mg 3 times per day, but 1 study found that a higher dose (1,800 mg/d) was associated with better outcomes.⁸ Common adverse effects include sedation, dizziness, peripheral edema, and ataxia.

Continue to: Topiramate

Topiramate blocks voltage-gated sodium channels and enhances GABA-A receptor activity.⁹ It is indicated for the treatment of seizures, migraine prophylaxis, weight management, and weight loss. Several clinical trials, including RCTs,^10-12 demonstrated that topiramate was superior to placebo in reducing the percentage of heavy drinking days and overall drinking days. Some also showed that topiramate was associated with abstinence and reduced craving levels.^12,13 A meta-analysis by Blodgett et al¹⁴ found that compared to placebo, topiramate lowered the rate of heavy drinking and increased abstinence.

Topiramate is dosed from 50 to 150 mg twice daily, although some studies suggest a lower dose (≤75 mg/d) may be associated with clinical benefits.^15,16 One important clinical consideration: topiramate must follow a slow titration schedule (4 to 6 weeks) to increase tolerability and avoid adverse effects. Common adverse effects include sedation, word-finding difficulty, paresthesia, increased risk for renal calculi, dizziness, anorexia, and alterations in taste.

Baclofen is a GABA-B agonist FDA-approved for the treatment of muscle spasticity related to multiple sclerosis and reversible spasticity related to spinal cord lesions and multiple sclerosis. Of note, it is approved for treatment of AUD in Europe.

In a meta-analysis of 13 RCTs, Pierce et al¹⁷ found a greater likelihood of abstinence and greater time to first lapse of drinking with baclofen compared to placebo. Interestingly, a subgroup analysis found that the positive effects were limited to trials that used 30 to 60 mg/d of baclofen, and not evident in those that used higher doses. Additionally, there was no difference between baclofen and placebo with regard to several important outcomes, including alcohol cravings, anxiety, depression, or number of total abstinent days. A review by Andrade¹⁸ proposed that individualized treatment with high-dose baclofen (30 to 300 mg/d) may be a useful second-line approach in heavy drinkers who wish to reduce their alcohol intake.

Continue to: Before starting baclofen...

Before starting baclofen, patients should be informed about its adverse effects. Common adverse effects include sedation and motor impairment. More serious but less common adverse effects include seizures, respiratory depression with sleep apnea, severe mood disorders (ie, mania, depression, or suicide risk), and mental confusion. Baclofen should be gradually discontinued, because there is some risk of clinical withdrawal symptoms (ie, agitation, confusion, seizures, or delirium).

Among the medications discussed in this section, the evidence for gabapentin and topiramate is moderate to strong, while the evidence for baclofen is overall weaker or mixed. The American Psychiatric Association’s Practice Guideline suggests offering gabapentin or topiramate to patients with moderate to severe AUD whose goal is to achieve abstinence or reduce alcohol use, or those who prefer gabapentin or topiramate or cannot tolerate or have not responded to naltrexone and acamprosate.¹⁹ Clinicians must ensure patients have no contra­indications to the use of these medications. Due to the moderate quality evidence for a significant reduction in heavy drinking and increased abstinence,^14,20 a practice guideline from the US Department of Veterans Affairs and US Department of Defense²¹ recommends topiramate as 1 of 2 first-line treatments (the other is naltrexone). This guideline suggests gabapentin as a second-line treatment for AUD.²¹

Gambling disorder

CASE 2

Mr. P, age 28, seeks treatment for GD and cocaine use disorder. He reports a 7-year history of sports betting that has increasingly impaired his functioning over the past year. He lost his job, savings, and familial relationships due to his impulsive and risky behavior. Mr. P also reports frequent cocaine use, about 2 to 3 days per week, mostly on the weekends. The psychiatrist tells Mr. P there is no FDA-approved pharmacologic treatment for GD or cocaine use disorder. The psychiatrist discusses the option of naltrexone as off-label treatment for GD with the goal of reducing Mr. P’s urges to gamble, and points to possible benefits for cocaine use disorder.

GD impacts approximately 0.5% of the adult US population and is often co-occurring with substance use disorders.²² It is thought to share neurobiological and clinical similarities with substance use disorders.²³ There are currently no FDA-approved medications to treat the disorder. In studies of GD, treatment success with antidepressants and mood stabilizers has not been consistent,^23,24 but some promising results have been published for the opioid receptor antagonist naltrexone^24-29and N-acetylcysteine (NAC).^30-32

Naltrexone is thought to reduce gambling behavior and urges via downstream modulation of mesolimbic dopamine circuitry.²⁴ It is FDA-approved for the treatment of AUD and opioid use disorder. Open-label RCTs have found a reduction in gambling urges and behavior with daily naltrexone.^25-27 Dosing at 50 mg/d appears to be just as efficacious as higher doses such as 100 and 150 mg/d.²⁷ When used as a daily as-needed medication for strong gambling urges or if an individual was planning to gamble, naltrexone 50 mg/d was not effective.²⁸

Continue to: Naltrexone typically is started...

Naltrexone typically is started at 25 mg/d to assess tolerability and quickly titrated to 50 mg/d. When titrating, common adverse effects include nausea, vomiting, and transient elevations in transaminases. Another opioid antagonist, nalmefene, has also been studied in patients with GD. An RCT by Grant et al²⁹ that evaluated 207 patients found that compared with placebo, nalmefene 25 mg/d for 16 weeks was associated with a significant reduction in gambling assessment scores. In Europe, nalmefene is approved for treating AUD but the oral formulation is not currently available in the US.

N-acetylcysteine is thought to potentially reverse neuronal dysfunction seen in addictive disorders by glutamatergic modulation.³⁰ Research investigating NAC for GD is scarce. A pilot study found 16 of 27 patients with GD reduced gambling behavior with a mean dose of 1,476.9 mg/d.³¹ An additional study investigating the addition of NAC to behavioral therapy in nicotine-dependent individuals with pathologic gambling found a reduction in problem gambling after 18 weeks (6 weeks + 3 months follow-up).³² Common but mild adverse effects associated with NAC are nausea, vomiting, and diarrhea.

A meta-analysis by Goslar et al³³ that reviewed 34 studies (1,340 participants) found pharmacologic treatments were associated with large and medium pre-post reductions in global severity, frequency, and financial loss in patients with GD. RCTs studying opioid antagonists and mood stabilizers (combined with a cognitive intervention) as well as lithium for patients with comorbid bipolar disorder and GD demonstrated promising results.³³

Stimulant use disorder

There are no FDA-approved medications for stimulant use disorder. Multiple off-label options have been studied for the treatment of methamphetamine abuse and cocaine abuse.

Methamphetamine use has been expanding over the past decade with a 3.6-fold increase in positive methamphetamine screens in overdose deaths from 2011 to 2016.³⁴ Pharmacologic options studied for OLP of methamphetamine use disorder include mirtazapine, bupropion, naltrexone, and topiramate.

Continue to: Mirtazapine

Mirtazapine is an atypical antidepressant whose mechanism of action includes modulation of the serotonin, norepinephrine, and alpha-2 adrenergic systems. It is FDA-approved for the treatment of major depressive disorder (MDD). In a randomized placebo-controlled study, mirtazapine 30 mg/d at night was found to decrease methamphetamine use for active users and led to decreased sexual risk in men who have sex with men.³⁵ These results were supported by an additional RCT in which mirtazapine 30 mg/d significantly reduced rates of methamphetamine use vs placebo at 24 and 36 weeks despite poor medication adherence.³⁶ Adverse effects to monitor in patients treated with mirtazapine include increased appetite, weight gain, sedation, and constipation.

Bupropion is a norepinephrine dopamine reuptake inhibitor that produces increased neurotransmission of norepinephrine and dopamine in the CNS. It is FDA-approved for the treatment of MDD and as an aid for smoking cessation. Bupropion has been studied for methamphetamine use disorder with mixed results. In a randomized placebo-controlled trial, bupropion sustained release 150 mg twice daily was not more effective than placebo in reducing methamphetamine use.³⁷ However, the extended-release formulation of bupropion 450 mg/d combined with long-acting injectable naltrexone was associated with a reduction in methamphetamine use over 12 weeks.³⁸ Bupropion is generally well tolerated; common adverse effects include insomnia, tremor, headache, and dizziness.

Naltrexone. Data about using oral naltrexone to treat stimulant use disorders are limited. A randomized, placebo-controlled trial by Jayaram-Lindström et al³⁹ found naltrexone 50 mg/d significantly reduced amphetamine use compared to placebo. Additionally, naltrexone 50 and 150 mg/d have been shown to reduce cocaine use over time in combination with therapy for cocaine-dependent patients and those dependent on alcohol and cocaine.^40,41

Topiramate has been studied for the treatment of cocaine use disorder. It is hypothesized that modulation of the mesocorticolimbic dopamine system may contribute to decreased cocaine cravings.⁴² A pilot study by Kampman et al⁴³ found that after an 8-week titration of topiramate to 200 mg/d, individuals were more likely to achieve cocaine abstinence compared to those who receive placebo. In an RCT, Elkashef et al⁴⁴ did not find topiramate assisted with increased abstinence of methamphetamine in active users at a target dose of 200 mg/d. However, it was associated with reduced relapse rates in individuals who were abstinent prior to the study.⁴⁴ At a target dose of 300 mg/d, topiramate also outperformed placebo in decreasing days of cocaine use.⁴² Adverse effects of topiramate included paresthesia, alteration in taste, and difficulty with concentration.

Cannabis use disorder

In recent years, cannabis use in the US has greatly increased⁴⁵ but no medications are FDA-approved for treating cannabis use disorder. Studies of pharmacologic options for cannabis use disorder have had mixed results.⁴⁶ A meta-analysis by Bahji et al⁴⁷ of 24 studies investigating pharmacotherapies for cannabis use disorder highlighted the lack of adequate evidence. In this section, we focus on a few positive trials of NAC and gabapentin.

Continue to: N-acetylcysteine

N-acetylcysteine. Studies investigating NAC 1,200 mg twice daily have been promising in adolescent and adult populations.^48-50 There are some mixed results, however. A large RCT found NAC 1,200 mg twice daily was not better than placebo in helping adults achieve abstinence from cannabis.⁵¹

Gabapentin may be a viable option for treating cannabis use disorder. A pilot study by Mason et al⁵² found gabapentin 1,200 mg/d was more effective than placebo at reducing cannabis use among treatment-seeking adults.

When and how to consider OLP

OLP for addictive disorders is common and often necessary. This is primarily due to limitations of the FDA-approved medications and because there are no FDA-approved medications for many substance-related and addictive disorders (ie, GD, cannabis use disorder, and stimulant use disorder). When assessing pharmacotherapy options, if FDA-approved medications are available for certain diagnoses, clinicians should first consider them. The off-label medications discussed in this article are outlined in the Table.^{6-21,24-28,30-33,35-44,48-52}

The overall level of evidence to support the use of off-label medications is lower than that of FDA-approved medications, which contributes to potential medicolegal concerns of OLP. Off-label medications should be considered when there are no FDA-approved medications available, and the decision to use off-label medications should be based on evidence from the literature and current standard of care. Additionally, OLP is necessary if a patient cannot tolerate FDA-approved medications, is not helped by FDA-approved treatments, or when there are other clinical reasons to choose a particular off-label medication. For example, if a patient has comorbid AUD and obesity (or migraines), using topiramate may be appropriate because it may target alcohol cravings and can be helpful for weight loss (and migraine prophylaxis). Similarly, for patients with AUD and neuropathic pain, using gabapentin can be considered for its dual therapeutic effects.

It is critical for clinicians to understand the landscape of off-label options for treating addictive disorders. Additional research in the form of RCTs is needed to better clarify the efficacy and adverse effects of these treatments.

Continue to: Bottom Line

Off-label prescribing is prevalent in practice, including in the treatment of substance-related and addictive disorders. When considering off-label use of any medication, clinicians should review the most recent research, obtain informed consent from patients, and verify patients’ understanding of the potential risks and adverse effects associated with the particular medication.

Related Resources

• Joshi KG, Frierson RL. Off-label prescribing: how to limit your liability. Current Psychiatry. 2020;19(9):12,39. doi:10.12788/ cp.0035
• Stanciu CN, Gnanasegaram SA. Don’t balk at using medical therapy to manage alcohol use disorder. Current Psychiatry. 2017;16(2):50-52.

Drug Brand Names

Acamprosate • Campral
Baclofen • Ozobax
Bupropion • Wellbutrin, Zyban
Disulfiram • Antabuse
Gabapentin • Neurontin
Lithium • Eskalith, Lithobid
Mirtazapine • Remeron
Naltrexone • ReVia, Vivitrol
Topiramate • Topamax

Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.¹ A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.^2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.^9,10 Surgeon burnout was also found to compromise the delivery of medical care.^9,10

To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.  

Methods

To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty.  Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹¹ and is outlined in the Supplemental Figure.

Results

Surgical specialties and burnout

We identified 56 studies^2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 2^2-10,12-58 lists these studies and the surgical specialties they evaluated.

Work/life balance factors

Fifteen studies^{2-5,14,15,18,19,22,32,34,38,39,47,57} examined the role of work/life balance in burnout. Table 1^{2-5,14,15,18,19,22,32,34,38,39,47,57} lists the work/life factors these studies identified as being linked to burnout. Six studies^{2,4,18,22,32,47} discussed how decreased leisure time was linked to burnout. Eleven studies^{2,4,14,15,19,22,34,38,39,42,57} associated inabilities to meet family commitments with burnout. A lack of time to spend with family and not having adequate time to raise children was more prevalent among women. Seven studies^{2,3,18,22,32,34,47} implicated increased time commitment to work as playing a role in burnout. This increased time commitment was also found to be a compounding variable for other factors, such as limited time for family and leisure.

Work hours

Fifteen studies^{2,7,14,20,21,30,34,41,42,44-46,50,52,56} examined work hours and burnout. Of these, 14^{2,7,14,20,21,30,34,42,44-46,50,52,56} found a correlation between increased work hours and burnout, while only 1 study⁴¹ found no correlation between these factors. 

Medical errors

Six studies^{2,14,18,43,49,52} discussed the role of burnout in medical errors. Of these, 5^{2,14,43,49,52} reported a correlation between burnout and medical errors, while 1 study¹⁸ found no link between burnout and medical errors. The medical errors were self-reported.^14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.²

Continue to: Institutional and organizational factors

Eighteen studies^{3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57} examined how different organizational factors play a role in burnout. Four studies^3,13,20,37 discussed administrative/bureaucratic work, 4^20,45,54,57 mentioned electronic medical documentation, 2^22,30 covered duty hour regulations, 3^18,45,57 discussed mistreatment of physicians, and 6^{13,18,23,44,47,56} described the importance of workplace support in addressing burnout.

Physical and mental health factors

Eighteen studies^{6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59} discussed aspects of physical and mental health linked to burnout. Among these, 3^34,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies^6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies^{26,29,43,44,48} described the systematic barriers that inhibit physicians from getting professional help. Two studies^7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies^{6,14,15,54,57} outlined how depression is associated with burnout.

Strategies to mitigate burnout

Fifteen studies^{2,4,5,14,20,22,33,36,47,51,53,55-58} described strategies physicians use to cope with burnout. Table 2^{2,4,5,14,20,22,33,36,47,51,53,55-58} outlines the strategies postulated and reported by these studies as helpful in reducing burnout. Two studies^2,4 mentioned that physicians may turn to maladaptive behaviors, such as substance abuse, to cope with stress and burnout. Four studies^2,4,53,56 mentioned the importance of social support in fighting burnout and building resilience. Ten studies^{2,5,14,20,22,33,36,47,57,58} described the benefits of institutional interventions, such as what administrators can do to reduce the rate of burnout. Three studies^5,36,53 postulated different adaptive behaviors physicians can implement to reduce burnout.

Take-home points 

Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.⁵⁶ One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.⁴ A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).²⁴ The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.³⁴ Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.¹⁵ A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.

Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.⁹ The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.⁴⁹ On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.⁴³

Continue to: In response to resident complaints...

In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.³⁰ This rule has been found to increase quality of life and prevent burnout.³⁰

The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.⁴⁵ It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.

A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.⁵⁷ The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.⁵⁷

Burnout has been positively correlated with anxiety and depression.⁶ A recent study reported that 13% of orthopedic surgery residents screened positive for depression.⁴⁴ Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.¹⁷ In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,⁵⁸ both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.⁵⁴ These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.⁴

Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.⁶ Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.⁶ One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.⁵⁹

Continue to: The amount of burnout physicians...

The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.^6,37,54 Resilience training and maintaining low stress at work can decrease burnout.³⁷ These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.

Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.^26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.⁵⁴ It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.³⁴

Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.¹⁸ Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.¹³ Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.¹⁸ The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.²⁹

Bottom Line

Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.

Related Resources

• Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
• Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.

Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.¹ A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.^2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.^9,10 Surgeon burnout was also found to compromise the delivery of medical care.^9,10

To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.  

Methods

To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty.  Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹¹ and is outlined in the Supplemental Figure.

Results

Surgical specialties and burnout

We identified 56 studies^2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 2^2-10,12-58 lists these studies and the surgical specialties they evaluated.

Work/life balance factors

Fifteen studies^{2-5,14,15,18,19,22,32,34,38,39,47,57} examined the role of work/life balance in burnout. Table 1^{2-5,14,15,18,19,22,32,34,38,39,47,57} lists the work/life factors these studies identified as being linked to burnout. Six studies^{2,4,18,22,32,47} discussed how decreased leisure time was linked to burnout. Eleven studies^{2,4,14,15,19,22,34,38,39,42,57} associated inabilities to meet family commitments with burnout. A lack of time to spend with family and not having adequate time to raise children was more prevalent among women. Seven studies^{2,3,18,22,32,34,47} implicated increased time commitment to work as playing a role in burnout. This increased time commitment was also found to be a compounding variable for other factors, such as limited time for family and leisure.

Work hours

Fifteen studies^{2,7,14,20,21,30,34,41,42,44-46,50,52,56} examined work hours and burnout. Of these, 14^{2,7,14,20,21,30,34,42,44-46,50,52,56} found a correlation between increased work hours and burnout, while only 1 study⁴¹ found no correlation between these factors. 

Medical errors

Six studies^{2,14,18,43,49,52} discussed the role of burnout in medical errors. Of these, 5^{2,14,43,49,52} reported a correlation between burnout and medical errors, while 1 study¹⁸ found no link between burnout and medical errors. The medical errors were self-reported.^14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.²

Continue to: Institutional and organizational factors

Eighteen studies^{3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57} examined how different organizational factors play a role in burnout. Four studies^3,13,20,37 discussed administrative/bureaucratic work, 4^20,45,54,57 mentioned electronic medical documentation, 2^22,30 covered duty hour regulations, 3^18,45,57 discussed mistreatment of physicians, and 6^{13,18,23,44,47,56} described the importance of workplace support in addressing burnout.

Physical and mental health factors

Eighteen studies^{6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59} discussed aspects of physical and mental health linked to burnout. Among these, 3^34,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies^6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies^{26,29,43,44,48} described the systematic barriers that inhibit physicians from getting professional help. Two studies^7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies^{6,14,15,54,57} outlined how depression is associated with burnout.

Strategies to mitigate burnout

Fifteen studies^{2,4,5,14,20,22,33,36,47,51,53,55-58} described strategies physicians use to cope with burnout. Table 2^{2,4,5,14,20,22,33,36,47,51,53,55-58} outlines the strategies postulated and reported by these studies as helpful in reducing burnout. Two studies^2,4 mentioned that physicians may turn to maladaptive behaviors, such as substance abuse, to cope with stress and burnout. Four studies^2,4,53,56 mentioned the importance of social support in fighting burnout and building resilience. Ten studies^{2,5,14,20,22,33,36,47,57,58} described the benefits of institutional interventions, such as what administrators can do to reduce the rate of burnout. Three studies^5,36,53 postulated different adaptive behaviors physicians can implement to reduce burnout.

Take-home points 

Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.⁵⁶ One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.⁴ A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).²⁴ The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.³⁴ Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.¹⁵ A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.

Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.⁹ The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.⁴⁹ On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.⁴³

Continue to: In response to resident complaints...

In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.³⁰ This rule has been found to increase quality of life and prevent burnout.³⁰

The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.⁴⁵ It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.

A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.⁵⁷ The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.⁵⁷

Burnout has been positively correlated with anxiety and depression.⁶ A recent study reported that 13% of orthopedic surgery residents screened positive for depression.⁴⁴ Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.¹⁷ In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,⁵⁸ both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.⁵⁴ These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.⁴

Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.⁶ Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.⁶ One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.⁵⁹

Continue to: The amount of burnout physicians...

The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.^6,37,54 Resilience training and maintaining low stress at work can decrease burnout.³⁷ These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.

Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.^26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.⁵⁴ It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.³⁴

Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.¹⁸ Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.¹³ Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.¹⁸ The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.²⁹

Bottom Line

Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.

Related Resources

• Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
• Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.

Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.¹ A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.^2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.^9,10 Surgeon burnout was also found to compromise the delivery of medical care.^9,10

To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.  

Methods

To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty.  Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹¹ and is outlined in the Supplemental Figure.

Results

Surgical specialties and burnout

We identified 56 studies^2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 2^2-10,12-58 lists these studies and the surgical specialties they evaluated.

Work/life balance factors

Fifteen studies^{2-5,14,15,18,19,22,32,34,38,39,47,57} examined the role of work/life balance in burnout. Table 1^{2-5,14,15,18,19,22,32,34,38,39,47,57} lists the work/life factors these studies identified as being linked to burnout. Six studies^{2,4,18,22,32,47} discussed how decreased leisure time was linked to burnout. Eleven studies^{2,4,14,15,19,22,34,38,39,42,57} associated inabilities to meet family commitments with burnout. A lack of time to spend with family and not having adequate time to raise children was more prevalent among women. Seven studies^{2,3,18,22,32,34,47} implicated increased time commitment to work as playing a role in burnout. This increased time commitment was also found to be a compounding variable for other factors, such as limited time for family and leisure.

Work hours

Fifteen studies^{2,7,14,20,21,30,34,41,42,44-46,50,52,56} examined work hours and burnout. Of these, 14^{2,7,14,20,21,30,34,42,44-46,50,52,56} found a correlation between increased work hours and burnout, while only 1 study⁴¹ found no correlation between these factors. 

Medical errors

Six studies^{2,14,18,43,49,52} discussed the role of burnout in medical errors. Of these, 5^{2,14,43,49,52} reported a correlation between burnout and medical errors, while 1 study¹⁸ found no link between burnout and medical errors. The medical errors were self-reported.^14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.²

Continue to: Institutional and organizational factors

Eighteen studies^{3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57} examined how different organizational factors play a role in burnout. Four studies^3,13,20,37 discussed administrative/bureaucratic work, 4^20,45,54,57 mentioned electronic medical documentation, 2^22,30 covered duty hour regulations, 3^18,45,57 discussed mistreatment of physicians, and 6^{13,18,23,44,47,56} described the importance of workplace support in addressing burnout.

Physical and mental health factors

Eighteen studies^{6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59} discussed aspects of physical and mental health linked to burnout. Among these, 3^34,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies^6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies^{26,29,43,44,48} described the systematic barriers that inhibit physicians from getting professional help. Two studies^7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies^{6,14,15,54,57} outlined how depression is associated with burnout.

Strategies to mitigate burnout

Fifteen studies^{2,4,5,14,20,22,33,36,47,51,53,55-58} described strategies physicians use to cope with burnout. Table 2^{2,4,5,14,20,22,33,36,47,51,53,55-58} outlines the strategies postulated and reported by these studies as helpful in reducing burnout. Two studies^2,4 mentioned that physicians may turn to maladaptive behaviors, such as substance abuse, to cope with stress and burnout. Four studies^2,4,53,56 mentioned the importance of social support in fighting burnout and building resilience. Ten studies^{2,5,14,20,22,33,36,47,57,58} described the benefits of institutional interventions, such as what administrators can do to reduce the rate of burnout. Three studies^5,36,53 postulated different adaptive behaviors physicians can implement to reduce burnout.

Take-home points 

Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.⁵⁶ One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.⁴ A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).²⁴ The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.³⁴ Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.¹⁵ A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.

Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.⁹ The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.⁴⁹ On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.⁴³

Continue to: In response to resident complaints...

In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.³⁰ This rule has been found to increase quality of life and prevent burnout.³⁰

The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.⁴⁵ It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.

A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.⁵⁷ The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.⁵⁷

Burnout has been positively correlated with anxiety and depression.⁶ A recent study reported that 13% of orthopedic surgery residents screened positive for depression.⁴⁴ Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.¹⁷ In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,⁵⁸ both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.⁵⁴ These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.⁴

Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.⁶ Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.⁶ One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.⁵⁹

Continue to: The amount of burnout physicians...

The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.^6,37,54 Resilience training and maintaining low stress at work can decrease burnout.³⁷ These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.

Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.^26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.⁵⁴ It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.³⁴

Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.¹⁸ Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.¹³ Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.¹⁸ The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.²⁹

Bottom Line

Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.

Related Resources

• Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
• Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.

Bipolar disorder (BD) is a psychotic mood disorder. Like schizophrenia, it has been shown to be associated with significant degeneration and structural brain abnormalities with multiple relapses.^1,2

Just as I have always advocated preventing recurrences in schizophrenia by using long-acting injectable (LAI) antipsychotic formulations immediately after the first episode to prevent psychotic relapses and progressive brain damage,³ I strongly recommend using LAIs right after hospital discharge from the first manic episode. It is the most rational management approach for bipolar mania given the grave consequences of multiple episodes, which are so common in this psychotic mood disorder due to poor medication adherence.

In contrast to the depressive episodes of BD I, where patients have insight into their depression and seek psychiatric treatment, during a manic episode patients often have no insight (anosognosia) that they suffer from a serious brain disorder, and refuse treatment.⁴ In addition, young patients with BD I frequently discontinue their oral mood stabilizer or second-generation antipsychotic (which are approved for mania) because they miss the blissful euphoria and the buoyant physical and mental energy of their manic episodes. They are completely oblivious to (and uninformed about) the grave neurobiological damage of further manic episodes, which can condemn them to clinical, functional, and cognitive deterioration. These patients are also likely to become treatment-resistant, which has been labeled as “the malignant transformation of bipolar disorder.”⁵

The evidence for progressive brain tissue loss, clinical deterioration, functional decline, and treatment resistance is abundant.⁶ I was the lead investigator of the first study to report ventricular dilatation (which is a proxy for cortical atrophy) in bipolar mania,⁷ a discovery that was subsequently replicated by 2 dozen researchers. This was followed by numerous neuroimaging studies reporting a loss of volume across multiple brain regions, including the frontal lobe, temporal lobe, cerebellum, thalamus, hippocampus, and basal ganglia. BD is heterogeneous⁸ with 4 stages (Table 1⁹), and patients experience progressively worse brain structure and function with each stage.

Many patients with bipolar mania end up with poor clinical and functional outcomes, even when they respond well to initial treatment with lithium, anticonvulsant mood stabilizers, or second-generation antipsychotics. With their intentional nonadherence to oral medications leading to multiple recurrent relapses, these patients are at serious risk for neuroprogression and brain atrophic changes driven by multiple factors: inflammatory cytokines, increased cortical steroids, decreased neurotrophins, deceased neurogenesis, increased oxidative stress, and mitochondrial energy dysfunction. The consequences include progressive shortening of the interval between episodes with every relapse and loss of responsiveness to pharmacotherapy as the illness progresses.^6,10 Predictors of a downhill progression include genetic vulnerability, perinatal complication during fetal life, childhood trauma (physical, sexual, emotional, or neglect), substance use, stress, psychiatric/medial comorbidities, and especially the number of episodes.^9,11

Biomarkers have been reported in both the early and late stages of BD (Table 2¹²) as well as in postmortem studies (Table 3^8,13). They reflect the progressive neurodegenerative nature of recurrent BD I episodes as the disorder moves to the advanced stages. I summarize these stages in Table 1⁹ and Table 2¹² for the benefit of psychiatric clinicians who do not have access to the neuroscience journals where such findings are usually published.

BD I is also believed to be associated with accelerated aging^14,15 and an increased risk for dementia¹⁶ or cognitive deterioration.¹⁷ There is also an emerging hypothesis that neuroprogression and treatment resistance in BD is frequently associated with insulin resistance,¹⁸ peripheral inflammation,¹⁹ and blood-brain barrier permeability dysfunction.²⁰

The bottom line is that like patients with schizophrenia, where relapses lead to devastating consequences,²¹ those with BD are at a similar high risk for neuroprogression, which includes atrophy in several brain regions, treatment resistance, and functional disability. This underscores the urgency for implementing LAI therapy early in the illness, when the first manic episode (Stage 2) emerges after the prodrome (Stage 1). This is the best strategy to preserve brain health in persons with BD²² and to allow them to remain functional with their many intellectual gifts, such as eloquence, poetry, artistic talents, humor, and social skills. It is unfortunate that the combination of patients’ and clinicians’ reluctance to use an LAI early in the illness dooms many patients with BD to a potentially avoidable malignant outcome.

Bipolar disorder (BD) is a psychotic mood disorder. Like schizophrenia, it has been shown to be associated with significant degeneration and structural brain abnormalities with multiple relapses.^1,2

Just as I have always advocated preventing recurrences in schizophrenia by using long-acting injectable (LAI) antipsychotic formulations immediately after the first episode to prevent psychotic relapses and progressive brain damage,³ I strongly recommend using LAIs right after hospital discharge from the first manic episode. It is the most rational management approach for bipolar mania given the grave consequences of multiple episodes, which are so common in this psychotic mood disorder due to poor medication adherence.

In contrast to the depressive episodes of BD I, where patients have insight into their depression and seek psychiatric treatment, during a manic episode patients often have no insight (anosognosia) that they suffer from a serious brain disorder, and refuse treatment.⁴ In addition, young patients with BD I frequently discontinue their oral mood stabilizer or second-generation antipsychotic (which are approved for mania) because they miss the blissful euphoria and the buoyant physical and mental energy of their manic episodes. They are completely oblivious to (and uninformed about) the grave neurobiological damage of further manic episodes, which can condemn them to clinical, functional, and cognitive deterioration. These patients are also likely to become treatment-resistant, which has been labeled as “the malignant transformation of bipolar disorder.”⁵

The evidence for progressive brain tissue loss, clinical deterioration, functional decline, and treatment resistance is abundant.⁶ I was the lead investigator of the first study to report ventricular dilatation (which is a proxy for cortical atrophy) in bipolar mania,⁷ a discovery that was subsequently replicated by 2 dozen researchers. This was followed by numerous neuroimaging studies reporting a loss of volume across multiple brain regions, including the frontal lobe, temporal lobe, cerebellum, thalamus, hippocampus, and basal ganglia. BD is heterogeneous⁸ with 4 stages (Table 1⁹), and patients experience progressively worse brain structure and function with each stage.

Many patients with bipolar mania end up with poor clinical and functional outcomes, even when they respond well to initial treatment with lithium, anticonvulsant mood stabilizers, or second-generation antipsychotics. With their intentional nonadherence to oral medications leading to multiple recurrent relapses, these patients are at serious risk for neuroprogression and brain atrophic changes driven by multiple factors: inflammatory cytokines, increased cortical steroids, decreased neurotrophins, deceased neurogenesis, increased oxidative stress, and mitochondrial energy dysfunction. The consequences include progressive shortening of the interval between episodes with every relapse and loss of responsiveness to pharmacotherapy as the illness progresses.^6,10 Predictors of a downhill progression include genetic vulnerability, perinatal complication during fetal life, childhood trauma (physical, sexual, emotional, or neglect), substance use, stress, psychiatric/medial comorbidities, and especially the number of episodes.^9,11

Biomarkers have been reported in both the early and late stages of BD (Table 2¹²) as well as in postmortem studies (Table 3^8,13). They reflect the progressive neurodegenerative nature of recurrent BD I episodes as the disorder moves to the advanced stages. I summarize these stages in Table 1⁹ and Table 2¹² for the benefit of psychiatric clinicians who do not have access to the neuroscience journals where such findings are usually published.

BD I is also believed to be associated with accelerated aging^14,15 and an increased risk for dementia¹⁶ or cognitive deterioration.¹⁷ There is also an emerging hypothesis that neuroprogression and treatment resistance in BD is frequently associated with insulin resistance,¹⁸ peripheral inflammation,¹⁹ and blood-brain barrier permeability dysfunction.²⁰

The bottom line is that like patients with schizophrenia, where relapses lead to devastating consequences,²¹ those with BD are at a similar high risk for neuroprogression, which includes atrophy in several brain regions, treatment resistance, and functional disability. This underscores the urgency for implementing LAI therapy early in the illness, when the first manic episode (Stage 2) emerges after the prodrome (Stage 1). This is the best strategy to preserve brain health in persons with BD²² and to allow them to remain functional with their many intellectual gifts, such as eloquence, poetry, artistic talents, humor, and social skills. It is unfortunate that the combination of patients’ and clinicians’ reluctance to use an LAI early in the illness dooms many patients with BD to a potentially avoidable malignant outcome.

Bipolar disorder (BD) is a psychotic mood disorder. Like schizophrenia, it has been shown to be associated with significant degeneration and structural brain abnormalities with multiple relapses.^1,2

Just as I have always advocated preventing recurrences in schizophrenia by using long-acting injectable (LAI) antipsychotic formulations immediately after the first episode to prevent psychotic relapses and progressive brain damage,³ I strongly recommend using LAIs right after hospital discharge from the first manic episode. It is the most rational management approach for bipolar mania given the grave consequences of multiple episodes, which are so common in this psychotic mood disorder due to poor medication adherence.

In contrast to the depressive episodes of BD I, where patients have insight into their depression and seek psychiatric treatment, during a manic episode patients often have no insight (anosognosia) that they suffer from a serious brain disorder, and refuse treatment.⁴ In addition, young patients with BD I frequently discontinue their oral mood stabilizer or second-generation antipsychotic (which are approved for mania) because they miss the blissful euphoria and the buoyant physical and mental energy of their manic episodes. They are completely oblivious to (and uninformed about) the grave neurobiological damage of further manic episodes, which can condemn them to clinical, functional, and cognitive deterioration. These patients are also likely to become treatment-resistant, which has been labeled as “the malignant transformation of bipolar disorder.”⁵

The evidence for progressive brain tissue loss, clinical deterioration, functional decline, and treatment resistance is abundant.⁶ I was the lead investigator of the first study to report ventricular dilatation (which is a proxy for cortical atrophy) in bipolar mania,⁷ a discovery that was subsequently replicated by 2 dozen researchers. This was followed by numerous neuroimaging studies reporting a loss of volume across multiple brain regions, including the frontal lobe, temporal lobe, cerebellum, thalamus, hippocampus, and basal ganglia. BD is heterogeneous⁸ with 4 stages (Table 1⁹), and patients experience progressively worse brain structure and function with each stage.

Many patients with bipolar mania end up with poor clinical and functional outcomes, even when they respond well to initial treatment with lithium, anticonvulsant mood stabilizers, or second-generation antipsychotics. With their intentional nonadherence to oral medications leading to multiple recurrent relapses, these patients are at serious risk for neuroprogression and brain atrophic changes driven by multiple factors: inflammatory cytokines, increased cortical steroids, decreased neurotrophins, deceased neurogenesis, increased oxidative stress, and mitochondrial energy dysfunction. The consequences include progressive shortening of the interval between episodes with every relapse and loss of responsiveness to pharmacotherapy as the illness progresses.^6,10 Predictors of a downhill progression include genetic vulnerability, perinatal complication during fetal life, childhood trauma (physical, sexual, emotional, or neglect), substance use, stress, psychiatric/medial comorbidities, and especially the number of episodes.^9,11

Biomarkers have been reported in both the early and late stages of BD (Table 2¹²) as well as in postmortem studies (Table 3^8,13). They reflect the progressive neurodegenerative nature of recurrent BD I episodes as the disorder moves to the advanced stages. I summarize these stages in Table 1⁹ and Table 2¹² for the benefit of psychiatric clinicians who do not have access to the neuroscience journals where such findings are usually published.

BD I is also believed to be associated with accelerated aging^14,15 and an increased risk for dementia¹⁶ or cognitive deterioration.¹⁷ There is also an emerging hypothesis that neuroprogression and treatment resistance in BD is frequently associated with insulin resistance,¹⁸ peripheral inflammation,¹⁹ and blood-brain barrier permeability dysfunction.²⁰

The bottom line is that like patients with schizophrenia, where relapses lead to devastating consequences,²¹ those with BD are at a similar high risk for neuroprogression, which includes atrophy in several brain regions, treatment resistance, and functional disability. This underscores the urgency for implementing LAI therapy early in the illness, when the first manic episode (Stage 2) emerges after the prodrome (Stage 1). This is the best strategy to preserve brain health in persons with BD²² and to allow them to remain functional with their many intellectual gifts, such as eloquence, poetry, artistic talents, humor, and social skills. It is unfortunate that the combination of patients’ and clinicians’ reluctance to use an LAI early in the illness dooms many patients with BD to a potentially avoidable malignant outcome.

CASE Detoxification and preoccupation with parasites

Mr. H, age 51, has an extensive history of alcohol and methamphetamine use. He presents to the emergency department (ED) requesting inpatient detoxification. He says he had been drinking alcohol but is unable to say how much. His blood ethanol level is 61 mg/dL (unintoxicated level: <50 mg/dL), and a urine drug screen is positive for methamphetamine; Mr. H also admits to using fentanyl. The ED team treats Mr. H’s electrolyte abnormalities, initiates thiamine supplementation, and transfers him to a unit for inpatient withdrawal management.

On the detoxification unit, Mr. H receives a total of 1,950 mg of phenobarbital for alcohol withdrawal and stabilizes on a buprenorphine/naloxone maintenance dose of 8 mg/2 mg twice daily for methamphetamine and fentanyl use. Though he was not taking any psychiatric medications prior to his arrival at the ED, Mr. H agrees to restart quetiapine—which he took when he was younger for suspected bipolar depression—50 mg/d at bedtime.

During Mr. H’s 3-day detoxification, the psychiatry team evaluates him. Mr. H says he believes he is infested with worms. He describes a prior sensation of “meth mites,” or the feeling of bugs crawling under his skin, while using methamphetamines. However, Mr. H says his current infestation feels distinctively different, and he had continued to experience these sensations during prior periods of abstinence.

The psychiatry team expresses concern over his preoccupation with infestations, disheveled appearance, poor hygiene, and healed scars from excoriation. Mr. H also reports poor sleep and appetite and was observed writing an incomprehensible “experiment” on a paper towel. Due to his bizarre behavior, delusional thoughts, and concerns about his inability to care for himself, the team admits Mr. H to the acute inpatient psychiatric unit on a voluntary commitment.

HISTORY Long-standing drug use and repeated hospital visits

Mr. H reports a history of drug use. His first documented ED visit was >5 years before his current admission. He has a family history of substance abuse and reports previously using methamphetamine, heroin, and alcohol. Mr. H was never diagnosed with a psychiatric illness, but when he was younger, there were suspicions of bipolar depression, with no contributing family psychiatric history. Though he took quetiapine at an unspecified younger age, Mr. H did not follow through with any outpatient mental health services or medications.

Mr. H first reported infestation symptoms 6 months before his current inpatient admission, when he came to the ED with complaints of bumps on his arms and legs and reported seeing bugs in his carpet. He was prescribed permethrin 5% topical cream for suspected bedbug infestation.

In the 6 months prior to his current admission, Mr. H came to the hospital >20 times for various reasons, including methamphetamine abuse, alcohol withdrawal, opiate overdose, cellulitis, wound checks, and 3 visits for hallucinations for which he requested physical evaluation and medical care. His substance use was the suspected cause of his tactile and visual hallucinations of infestation because formication—the sensation of something crawling on your skin—is commonly associated with substance use. Although the etiology of Mr. H’s hallucinations was unclear, his substance use may have either precipitated them, or, as the team suspects, masked an underlying pathology that eventually became more evident and required psychiatric treatment.

Continue to: The authors' observations

The authors’ observations

Delusional parasitosis (DP), also known as delusional infestation or Ekbom Syndrome, is a condition characterized by the fixed, false belief of an infestation without any objective evidence. This condition was previously defined in DSM-IV, but was removed from DSM-5-TR. In DSM-5-TR, DP is most closely associated with delusional disorder—somatic type (Table 1¹). It describes a patient with ≥1 month of delusions who does not meet the criteria for schizophrenia with a central theme of delusions involving bodily functions or sensations such as infestation of insects or internal parasites.¹

DP is rare, affecting approximately 1.9 per 100,000 people. There has not been consistent data supporting differences in prevalence between sexes, but there is evidence for increasing incidence with age, with a mean age of diagnosis of 61.4.^2,3 DP can be divided into 2 types based on the history and etiology of the symptoms: primary DP and secondary DP. Primary DP occurs when there is a failure to identify an organic cause for the occurrence of the symptoms. Therefore, primary DP requires an extensive investigation by a multidisciplinary team that commonly includes medical specialists for a nonpsychiatric workup. Secondary DP occurs when the patient has delusional symptoms associated with a primary diagnosis of schizophrenia, depression, stroke, diabetes, vitamin B12 deficiency, or substance use.⁴

Though Mr. H initially presented to the ED, patients with DP commonly present to a primary care physician or dermatologist with the complaint of itching or feelings of insects, worms, or unclear organisms inside them. Patients with DP may often develop poor working relationships with physicians while obtaining multiple negative results. They may seek opinions from multiple specialists; however, patients typically do not consider psychiatrists as a source of help. When patients seek psychiatric care, often after a recommendation from a primary care physician or dermatologist, mental health clinicians should listen to and evaluate the patient holistically, continuing to rule out other possible etiologies.

[polldaddy:12570072]

TREATMENT Finding the right antipsychotic

In the psychiatric unit, Mr. H says he believes worms are exiting his ears, mouth, toenail, and self-inflicted scratch wounds. He believes he has been dealing with the parasites for >1 year and they are slowly draining his energy. Mr. H insists he contracted the “infection” from his home carpet, which was wet due to a flood in his house, and after he had fallen asleep following drug use. He also believes he acquired the parasites while walking barefoot along the beach and collecting rocks, and that there are multiple species living inside him, all intelligent enough to hide, making it difficult to prove their existence. He notes they vary in size, and some have red eyes.

During admission, Mr. H voices his frustration that clinicians had not found the worms he has been seeing. He continuously requests to review imaging performed during his visit and wants a multidisciplinary team to evaluate his case. He demands to test a cup with spit-up “samples,” believing the parasites would be visible under a microscope. Throughout his admission, Mr. H continues to take buprenorphine/naloxone and does not experience withdrawal symptoms. The treatment team titrates his quetiapine to 400 mg/d. Due to the lack of improvement, the team initiates olanzapine 5 mg/d at bedtime. However, Mr. H reports significant tinnitus and requests a medication change. He is started on haloperidol 5 mg twice daily.

Continue to: Mr. H begins to see improvements...

Mr. H begins to see improvements on Day 7 of taking haloperidol. He no longer brings up infestation but still acknowledges having worms inside him when directly asked. He says the worms cause him less distress than before and he is hopeful to live without discomfort. He also demonstrates an ability to conduct activities of daily living. Because Mr. H is being monitored on an acute inpatient psychiatric basis, he is deemed appropriate for discharge even though his symptoms have not yet fully resolved. After a 19-day hospital stay, Mr. H is discharged on haloperidol 15 mg/d and quetiapine 200 mg/d.

[polldaddy:12570074]

The authors’ observations

Mr. H asked to have his sputum examined. The “specimen sign,” also called “matchbox sign” or “Ziploc bag sign,” in which patients collect what they believe to be infected tissue or organisms in a container, is a well-studied part of DP.⁵ Such samples should be considered during initial encounters and can be examined for formal evaluation, but cautiously. Overtesting may incur a financial burden or reinforce deleterious beliefs and behaviors.

It can be difficult to identify triggers of DP. Research shows DP may arise from nonorganic and stressful life events, home floods, or contact with people infected with parasites.^6,7 Organic causes have also been found, such as patients taking multiple medications for Parkinson disease who developed delusional symptoms.⁸ Buscarino et al⁹ reported the case of a woman who started to develop symptoms of delusions and hallucinations after being on high-dose amphetamines for attention-deficit/hyperactivity disorder. Research shows that stopping the suspected medication commonly improves such symptoms.^9,10 Although methamphetamine can remain detectable in urine for up to 4 days after use and potentially a few days longer for chronic users due to circulating levels,¹¹ Mr. H’s symptoms continued for weeks after all substances of abuse should have been cleared from his system. This suggests he was experiencing a psychiatric illness and was accurate in distinguishing methamphetamine-induced from psychiatric-induced sensations. Regardless, polysubstance use has been shown to potentially increase the risk and play a role in the onset and progression of delusional illness, as seen in prior cases as well as in this case.⁹

It has been hypothesized that the pathophysiology of DP is associated with the deterioration of the striatal dopaminergic pathway, leading to an increase in extracellular dopamine levels. The striatum is responsible for most dopamine reuptake in the brain; therefore, certain drugs such as cocaine, methamphetamine, and methyl­phenidate may precipitate symptoms of DP due to their blockade of presynaptic dopamine reuptake.¹² Additionally, conditions that decrease the functioning of striatal dopamine transporters, such as schizophrenia or depression, may be underlying causes of DP.¹³

Treatment of DP remains a topic of debate. Most current recommendations appear to be based on a small, nonrandomized placebo-controlled trial.¹⁴ The first-generation antipsychotic pimozide had been a first-line treatment for DP, but its adverse effect profile, which includes QTc prolongation and extrapyramidal symptoms, led to the exploration of second-generation antipsychotics such as olanzapine and risperidone.^15,16 There is a dearth of literature about the use of haloperidol, quetiapine, or a combination of both as treatment options for DP, though the combination of these 2 medications proved effective for Mr. H. Further research is necessary to justify changes to current treatment standards, but this finding highlights a successful symptom reduction achieved with this combination.

Continue to: Patients may experience genuine symptoms...

Patients may experience genuine symptoms despite the delusional nature of DP, and it is important for clinicians to recognize the potential burden and anxiety these individuals face. Patients may present with self-inflicted bruises, cuts, and erosions to gain access to infected areas, which may be confused with skin picking disorder. Excessive cleansing or use of irritant products can also cause skin damage, leading to other dermatological conditions that reinforce the patient’s belief that something is medically wrong. During treatment, consider medications for relief of pruritus or pain. Focus on offering patients the opportunity to express their concerns, treat them with empathy, avoid stigmatizing language such as “delusions” or “psychosis,” and refrain from contradicting them until a strong rapport has been established (Table 2¹⁷).

Symptoms of DP can persist for months to years. Patients who fully recovered experienced a median duration of 0.5 years until symptom resolution, compared to incompletely recovered patients, who took approximately 1 year.¹⁸ Primary DP has slower improvement rates compared to secondary DP, with the median onset of effects occurring at Week 1.5 and peak improvements occurring at Week 6.¹⁶

OUTCOME Continued ED visits

Unfortunately, Mr. H does not follow through with his outpatient psychiatry appointments. In the 7 months following discharge, he visits the ED 8 times for alcohol intoxication, alcohol withdrawal, and methamphetamine abuse, in addition to 2 admissions for inpatient detoxification, during which he was still receiving the same scheduled medications (haloperidol 15 mg/d and quetiapine 200 mg/d). At each of his ED visits, there was no documentation of DP symptoms, which suggests his symptoms may have resolved.

Bottom Line

Because delusional parasitosis symptoms feel real to patients, it is crucial to build rapport to recommend and successfully initiate treatment. After ruling out nonpsychiatric etiologies, consider traditional treatment with antipsychotics, and consider medications for relief of pruritus or pain.

Related Resources

• Sellman D, Phan SV, Inyang M. Bugs on her skin—but nobody else sees them. Current Psychiatry. 2018;17(8):48,50-53.
• Campbell EH, Elston DM, Hawthorne JD, et al. Diagnosis and management of delusional parasitosis. J Am Acad Dermatol. 2019;80(5):1428-1434. doi:10.1016/j.jaad.2018.12.012

Drug Brand Names

Buprenorphine/naloxone • Suboxone
Haloperidol • Haldol
Hydroxyzine • Vistaril
Lithium • Eskalith, Lithobid
Methylphenidate • Concerta
Olanzapine • Zyprexa
Permethrin • Elimite
Phenobarbital • Solfoton, Tedral, Luminal
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Valproic acid • Depakote

CASE Detoxification and preoccupation with parasites

Mr. H, age 51, has an extensive history of alcohol and methamphetamine use. He presents to the emergency department (ED) requesting inpatient detoxification. He says he had been drinking alcohol but is unable to say how much. His blood ethanol level is 61 mg/dL (unintoxicated level: <50 mg/dL), and a urine drug screen is positive for methamphetamine; Mr. H also admits to using fentanyl. The ED team treats Mr. H’s electrolyte abnormalities, initiates thiamine supplementation, and transfers him to a unit for inpatient withdrawal management.

On the detoxification unit, Mr. H receives a total of 1,950 mg of phenobarbital for alcohol withdrawal and stabilizes on a buprenorphine/naloxone maintenance dose of 8 mg/2 mg twice daily for methamphetamine and fentanyl use. Though he was not taking any psychiatric medications prior to his arrival at the ED, Mr. H agrees to restart quetiapine—which he took when he was younger for suspected bipolar depression—50 mg/d at bedtime.

During Mr. H’s 3-day detoxification, the psychiatry team evaluates him. Mr. H says he believes he is infested with worms. He describes a prior sensation of “meth mites,” or the feeling of bugs crawling under his skin, while using methamphetamines. However, Mr. H says his current infestation feels distinctively different, and he had continued to experience these sensations during prior periods of abstinence.

The psychiatry team expresses concern over his preoccupation with infestations, disheveled appearance, poor hygiene, and healed scars from excoriation. Mr. H also reports poor sleep and appetite and was observed writing an incomprehensible “experiment” on a paper towel. Due to his bizarre behavior, delusional thoughts, and concerns about his inability to care for himself, the team admits Mr. H to the acute inpatient psychiatric unit on a voluntary commitment.

HISTORY Long-standing drug use and repeated hospital visits

Mr. H reports a history of drug use. His first documented ED visit was >5 years before his current admission. He has a family history of substance abuse and reports previously using methamphetamine, heroin, and alcohol. Mr. H was never diagnosed with a psychiatric illness, but when he was younger, there were suspicions of bipolar depression, with no contributing family psychiatric history. Though he took quetiapine at an unspecified younger age, Mr. H did not follow through with any outpatient mental health services or medications.

Mr. H first reported infestation symptoms 6 months before his current inpatient admission, when he came to the ED with complaints of bumps on his arms and legs and reported seeing bugs in his carpet. He was prescribed permethrin 5% topical cream for suspected bedbug infestation.

In the 6 months prior to his current admission, Mr. H came to the hospital >20 times for various reasons, including methamphetamine abuse, alcohol withdrawal, opiate overdose, cellulitis, wound checks, and 3 visits for hallucinations for which he requested physical evaluation and medical care. His substance use was the suspected cause of his tactile and visual hallucinations of infestation because formication—the sensation of something crawling on your skin—is commonly associated with substance use. Although the etiology of Mr. H’s hallucinations was unclear, his substance use may have either precipitated them, or, as the team suspects, masked an underlying pathology that eventually became more evident and required psychiatric treatment.

Continue to: The authors' observations

The authors’ observations

Delusional parasitosis (DP), also known as delusional infestation or Ekbom Syndrome, is a condition characterized by the fixed, false belief of an infestation without any objective evidence. This condition was previously defined in DSM-IV, but was removed from DSM-5-TR. In DSM-5-TR, DP is most closely associated with delusional disorder—somatic type (Table 1¹). It describes a patient with ≥1 month of delusions who does not meet the criteria for schizophrenia with a central theme of delusions involving bodily functions or sensations such as infestation of insects or internal parasites.¹

DP is rare, affecting approximately 1.9 per 100,000 people. There has not been consistent data supporting differences in prevalence between sexes, but there is evidence for increasing incidence with age, with a mean age of diagnosis of 61.4.^2,3 DP can be divided into 2 types based on the history and etiology of the symptoms: primary DP and secondary DP. Primary DP occurs when there is a failure to identify an organic cause for the occurrence of the symptoms. Therefore, primary DP requires an extensive investigation by a multidisciplinary team that commonly includes medical specialists for a nonpsychiatric workup. Secondary DP occurs when the patient has delusional symptoms associated with a primary diagnosis of schizophrenia, depression, stroke, diabetes, vitamin B12 deficiency, or substance use.⁴

Though Mr. H initially presented to the ED, patients with DP commonly present to a primary care physician or dermatologist with the complaint of itching or feelings of insects, worms, or unclear organisms inside them. Patients with DP may often develop poor working relationships with physicians while obtaining multiple negative results. They may seek opinions from multiple specialists; however, patients typically do not consider psychiatrists as a source of help. When patients seek psychiatric care, often after a recommendation from a primary care physician or dermatologist, mental health clinicians should listen to and evaluate the patient holistically, continuing to rule out other possible etiologies.

[polldaddy:12570072]

TREATMENT Finding the right antipsychotic

In the psychiatric unit, Mr. H says he believes worms are exiting his ears, mouth, toenail, and self-inflicted scratch wounds. He believes he has been dealing with the parasites for >1 year and they are slowly draining his energy. Mr. H insists he contracted the “infection” from his home carpet, which was wet due to a flood in his house, and after he had fallen asleep following drug use. He also believes he acquired the parasites while walking barefoot along the beach and collecting rocks, and that there are multiple species living inside him, all intelligent enough to hide, making it difficult to prove their existence. He notes they vary in size, and some have red eyes.

During admission, Mr. H voices his frustration that clinicians had not found the worms he has been seeing. He continuously requests to review imaging performed during his visit and wants a multidisciplinary team to evaluate his case. He demands to test a cup with spit-up “samples,” believing the parasites would be visible under a microscope. Throughout his admission, Mr. H continues to take buprenorphine/naloxone and does not experience withdrawal symptoms. The treatment team titrates his quetiapine to 400 mg/d. Due to the lack of improvement, the team initiates olanzapine 5 mg/d at bedtime. However, Mr. H reports significant tinnitus and requests a medication change. He is started on haloperidol 5 mg twice daily.

Continue to: Mr. H begins to see improvements...

Mr. H begins to see improvements on Day 7 of taking haloperidol. He no longer brings up infestation but still acknowledges having worms inside him when directly asked. He says the worms cause him less distress than before and he is hopeful to live without discomfort. He also demonstrates an ability to conduct activities of daily living. Because Mr. H is being monitored on an acute inpatient psychiatric basis, he is deemed appropriate for discharge even though his symptoms have not yet fully resolved. After a 19-day hospital stay, Mr. H is discharged on haloperidol 15 mg/d and quetiapine 200 mg/d.

[polldaddy:12570074]

The authors’ observations

Mr. H asked to have his sputum examined. The “specimen sign,” also called “matchbox sign” or “Ziploc bag sign,” in which patients collect what they believe to be infected tissue or organisms in a container, is a well-studied part of DP.⁵ Such samples should be considered during initial encounters and can be examined for formal evaluation, but cautiously. Overtesting may incur a financial burden or reinforce deleterious beliefs and behaviors.

It can be difficult to identify triggers of DP. Research shows DP may arise from nonorganic and stressful life events, home floods, or contact with people infected with parasites.^6,7 Organic causes have also been found, such as patients taking multiple medications for Parkinson disease who developed delusional symptoms.⁸ Buscarino et al⁹ reported the case of a woman who started to develop symptoms of delusions and hallucinations after being on high-dose amphetamines for attention-deficit/hyperactivity disorder. Research shows that stopping the suspected medication commonly improves such symptoms.^9,10 Although methamphetamine can remain detectable in urine for up to 4 days after use and potentially a few days longer for chronic users due to circulating levels,¹¹ Mr. H’s symptoms continued for weeks after all substances of abuse should have been cleared from his system. This suggests he was experiencing a psychiatric illness and was accurate in distinguishing methamphetamine-induced from psychiatric-induced sensations. Regardless, polysubstance use has been shown to potentially increase the risk and play a role in the onset and progression of delusional illness, as seen in prior cases as well as in this case.⁹

It has been hypothesized that the pathophysiology of DP is associated with the deterioration of the striatal dopaminergic pathway, leading to an increase in extracellular dopamine levels. The striatum is responsible for most dopamine reuptake in the brain; therefore, certain drugs such as cocaine, methamphetamine, and methyl­phenidate may precipitate symptoms of DP due to their blockade of presynaptic dopamine reuptake.¹² Additionally, conditions that decrease the functioning of striatal dopamine transporters, such as schizophrenia or depression, may be underlying causes of DP.¹³

Treatment of DP remains a topic of debate. Most current recommendations appear to be based on a small, nonrandomized placebo-controlled trial.¹⁴ The first-generation antipsychotic pimozide had been a first-line treatment for DP, but its adverse effect profile, which includes QTc prolongation and extrapyramidal symptoms, led to the exploration of second-generation antipsychotics such as olanzapine and risperidone.^15,16 There is a dearth of literature about the use of haloperidol, quetiapine, or a combination of both as treatment options for DP, though the combination of these 2 medications proved effective for Mr. H. Further research is necessary to justify changes to current treatment standards, but this finding highlights a successful symptom reduction achieved with this combination.

Continue to: Patients may experience genuine symptoms...

Patients may experience genuine symptoms despite the delusional nature of DP, and it is important for clinicians to recognize the potential burden and anxiety these individuals face. Patients may present with self-inflicted bruises, cuts, and erosions to gain access to infected areas, which may be confused with skin picking disorder. Excessive cleansing or use of irritant products can also cause skin damage, leading to other dermatological conditions that reinforce the patient’s belief that something is medically wrong. During treatment, consider medications for relief of pruritus or pain. Focus on offering patients the opportunity to express their concerns, treat them with empathy, avoid stigmatizing language such as “delusions” or “psychosis,” and refrain from contradicting them until a strong rapport has been established (Table 2¹⁷).

Symptoms of DP can persist for months to years. Patients who fully recovered experienced a median duration of 0.5 years until symptom resolution, compared to incompletely recovered patients, who took approximately 1 year.¹⁸ Primary DP has slower improvement rates compared to secondary DP, with the median onset of effects occurring at Week 1.5 and peak improvements occurring at Week 6.¹⁶

OUTCOME Continued ED visits

Unfortunately, Mr. H does not follow through with his outpatient psychiatry appointments. In the 7 months following discharge, he visits the ED 8 times for alcohol intoxication, alcohol withdrawal, and methamphetamine abuse, in addition to 2 admissions for inpatient detoxification, during which he was still receiving the same scheduled medications (haloperidol 15 mg/d and quetiapine 200 mg/d). At each of his ED visits, there was no documentation of DP symptoms, which suggests his symptoms may have resolved.

Bottom Line

Because delusional parasitosis symptoms feel real to patients, it is crucial to build rapport to recommend and successfully initiate treatment. After ruling out nonpsychiatric etiologies, consider traditional treatment with antipsychotics, and consider medications for relief of pruritus or pain.

Related Resources

• Sellman D, Phan SV, Inyang M. Bugs on her skin—but nobody else sees them. Current Psychiatry. 2018;17(8):48,50-53.
• Campbell EH, Elston DM, Hawthorne JD, et al. Diagnosis and management of delusional parasitosis. J Am Acad Dermatol. 2019;80(5):1428-1434. doi:10.1016/j.jaad.2018.12.012

Drug Brand Names

Buprenorphine/naloxone • Suboxone
Haloperidol • Haldol
Hydroxyzine • Vistaril
Lithium • Eskalith, Lithobid
Methylphenidate • Concerta
Olanzapine • Zyprexa
Permethrin • Elimite
Phenobarbital • Solfoton, Tedral, Luminal
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Valproic acid • Depakote

CASE Detoxification and preoccupation with parasites

Mr. H, age 51, has an extensive history of alcohol and methamphetamine use. He presents to the emergency department (ED) requesting inpatient detoxification. He says he had been drinking alcohol but is unable to say how much. His blood ethanol level is 61 mg/dL (unintoxicated level: <50 mg/dL), and a urine drug screen is positive for methamphetamine; Mr. H also admits to using fentanyl. The ED team treats Mr. H’s electrolyte abnormalities, initiates thiamine supplementation, and transfers him to a unit for inpatient withdrawal management.

On the detoxification unit, Mr. H receives a total of 1,950 mg of phenobarbital for alcohol withdrawal and stabilizes on a buprenorphine/naloxone maintenance dose of 8 mg/2 mg twice daily for methamphetamine and fentanyl use. Though he was not taking any psychiatric medications prior to his arrival at the ED, Mr. H agrees to restart quetiapine—which he took when he was younger for suspected bipolar depression—50 mg/d at bedtime.

During Mr. H’s 3-day detoxification, the psychiatry team evaluates him. Mr. H says he believes he is infested with worms. He describes a prior sensation of “meth mites,” or the feeling of bugs crawling under his skin, while using methamphetamines. However, Mr. H says his current infestation feels distinctively different, and he had continued to experience these sensations during prior periods of abstinence.

The psychiatry team expresses concern over his preoccupation with infestations, disheveled appearance, poor hygiene, and healed scars from excoriation. Mr. H also reports poor sleep and appetite and was observed writing an incomprehensible “experiment” on a paper towel. Due to his bizarre behavior, delusional thoughts, and concerns about his inability to care for himself, the team admits Mr. H to the acute inpatient psychiatric unit on a voluntary commitment.

HISTORY Long-standing drug use and repeated hospital visits

Mr. H reports a history of drug use. His first documented ED visit was >5 years before his current admission. He has a family history of substance abuse and reports previously using methamphetamine, heroin, and alcohol. Mr. H was never diagnosed with a psychiatric illness, but when he was younger, there were suspicions of bipolar depression, with no contributing family psychiatric history. Though he took quetiapine at an unspecified younger age, Mr. H did not follow through with any outpatient mental health services or medications.

Mr. H first reported infestation symptoms 6 months before his current inpatient admission, when he came to the ED with complaints of bumps on his arms and legs and reported seeing bugs in his carpet. He was prescribed permethrin 5% topical cream for suspected bedbug infestation.

In the 6 months prior to his current admission, Mr. H came to the hospital >20 times for various reasons, including methamphetamine abuse, alcohol withdrawal, opiate overdose, cellulitis, wound checks, and 3 visits for hallucinations for which he requested physical evaluation and medical care. His substance use was the suspected cause of his tactile and visual hallucinations of infestation because formication—the sensation of something crawling on your skin—is commonly associated with substance use. Although the etiology of Mr. H’s hallucinations was unclear, his substance use may have either precipitated them, or, as the team suspects, masked an underlying pathology that eventually became more evident and required psychiatric treatment.

Continue to: The authors' observations

The authors’ observations

Delusional parasitosis (DP), also known as delusional infestation or Ekbom Syndrome, is a condition characterized by the fixed, false belief of an infestation without any objective evidence. This condition was previously defined in DSM-IV, but was removed from DSM-5-TR. In DSM-5-TR, DP is most closely associated with delusional disorder—somatic type (Table 1¹). It describes a patient with ≥1 month of delusions who does not meet the criteria for schizophrenia with a central theme of delusions involving bodily functions or sensations such as infestation of insects or internal parasites.¹

DP is rare, affecting approximately 1.9 per 100,000 people. There has not been consistent data supporting differences in prevalence between sexes, but there is evidence for increasing incidence with age, with a mean age of diagnosis of 61.4.^2,3 DP can be divided into 2 types based on the history and etiology of the symptoms: primary DP and secondary DP. Primary DP occurs when there is a failure to identify an organic cause for the occurrence of the symptoms. Therefore, primary DP requires an extensive investigation by a multidisciplinary team that commonly includes medical specialists for a nonpsychiatric workup. Secondary DP occurs when the patient has delusional symptoms associated with a primary diagnosis of schizophrenia, depression, stroke, diabetes, vitamin B12 deficiency, or substance use.⁴

Though Mr. H initially presented to the ED, patients with DP commonly present to a primary care physician or dermatologist with the complaint of itching or feelings of insects, worms, or unclear organisms inside them. Patients with DP may often develop poor working relationships with physicians while obtaining multiple negative results. They may seek opinions from multiple specialists; however, patients typically do not consider psychiatrists as a source of help. When patients seek psychiatric care, often after a recommendation from a primary care physician or dermatologist, mental health clinicians should listen to and evaluate the patient holistically, continuing to rule out other possible etiologies.

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TREATMENT Finding the right antipsychotic

In the psychiatric unit, Mr. H says he believes worms are exiting his ears, mouth, toenail, and self-inflicted scratch wounds. He believes he has been dealing with the parasites for >1 year and they are slowly draining his energy. Mr. H insists he contracted the “infection” from his home carpet, which was wet due to a flood in his house, and after he had fallen asleep following drug use. He also believes he acquired the parasites while walking barefoot along the beach and collecting rocks, and that there are multiple species living inside him, all intelligent enough to hide, making it difficult to prove their existence. He notes they vary in size, and some have red eyes.

During admission, Mr. H voices his frustration that clinicians had not found the worms he has been seeing. He continuously requests to review imaging performed during his visit and wants a multidisciplinary team to evaluate his case. He demands to test a cup with spit-up “samples,” believing the parasites would be visible under a microscope. Throughout his admission, Mr. H continues to take buprenorphine/naloxone and does not experience withdrawal symptoms. The treatment team titrates his quetiapine to 400 mg/d. Due to the lack of improvement, the team initiates olanzapine 5 mg/d at bedtime. However, Mr. H reports significant tinnitus and requests a medication change. He is started on haloperidol 5 mg twice daily.

Continue to: Mr. H begins to see improvements...

Mr. H begins to see improvements on Day 7 of taking haloperidol. He no longer brings up infestation but still acknowledges having worms inside him when directly asked. He says the worms cause him less distress than before and he is hopeful to live without discomfort. He also demonstrates an ability to conduct activities of daily living. Because Mr. H is being monitored on an acute inpatient psychiatric basis, he is deemed appropriate for discharge even though his symptoms have not yet fully resolved. After a 19-day hospital stay, Mr. H is discharged on haloperidol 15 mg/d and quetiapine 200 mg/d.

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The authors’ observations

Mr. H asked to have his sputum examined. The “specimen sign,” also called “matchbox sign” or “Ziploc bag sign,” in which patients collect what they believe to be infected tissue or organisms in a container, is a well-studied part of DP.⁵ Such samples should be considered during initial encounters and can be examined for formal evaluation, but cautiously. Overtesting may incur a financial burden or reinforce deleterious beliefs and behaviors.

It can be difficult to identify triggers of DP. Research shows DP may arise from nonorganic and stressful life events, home floods, or contact with people infected with parasites.^6,7 Organic causes have also been found, such as patients taking multiple medications for Parkinson disease who developed delusional symptoms.⁸ Buscarino et al⁹ reported the case of a woman who started to develop symptoms of delusions and hallucinations after being on high-dose amphetamines for attention-deficit/hyperactivity disorder. Research shows that stopping the suspected medication commonly improves such symptoms.^9,10 Although methamphetamine can remain detectable in urine for up to 4 days after use and potentially a few days longer for chronic users due to circulating levels,¹¹ Mr. H’s symptoms continued for weeks after all substances of abuse should have been cleared from his system. This suggests he was experiencing a psychiatric illness and was accurate in distinguishing methamphetamine-induced from psychiatric-induced sensations. Regardless, polysubstance use has been shown to potentially increase the risk and play a role in the onset and progression of delusional illness, as seen in prior cases as well as in this case.⁹

It has been hypothesized that the pathophysiology of DP is associated with the deterioration of the striatal dopaminergic pathway, leading to an increase in extracellular dopamine levels. The striatum is responsible for most dopamine reuptake in the brain; therefore, certain drugs such as cocaine, methamphetamine, and methyl­phenidate may precipitate symptoms of DP due to their blockade of presynaptic dopamine reuptake.¹² Additionally, conditions that decrease the functioning of striatal dopamine transporters, such as schizophrenia or depression, may be underlying causes of DP.¹³

Treatment of DP remains a topic of debate. Most current recommendations appear to be based on a small, nonrandomized placebo-controlled trial.¹⁴ The first-generation antipsychotic pimozide had been a first-line treatment for DP, but its adverse effect profile, which includes QTc prolongation and extrapyramidal symptoms, led to the exploration of second-generation antipsychotics such as olanzapine and risperidone.^15,16 There is a dearth of literature about the use of haloperidol, quetiapine, or a combination of both as treatment options for DP, though the combination of these 2 medications proved effective for Mr. H. Further research is necessary to justify changes to current treatment standards, but this finding highlights a successful symptom reduction achieved with this combination.

Continue to: Patients may experience genuine symptoms...

Patients may experience genuine symptoms despite the delusional nature of DP, and it is important for clinicians to recognize the potential burden and anxiety these individuals face. Patients may present with self-inflicted bruises, cuts, and erosions to gain access to infected areas, which may be confused with skin picking disorder. Excessive cleansing or use of irritant products can also cause skin damage, leading to other dermatological conditions that reinforce the patient’s belief that something is medically wrong. During treatment, consider medications for relief of pruritus or pain. Focus on offering patients the opportunity to express their concerns, treat them with empathy, avoid stigmatizing language such as “delusions” or “psychosis,” and refrain from contradicting them until a strong rapport has been established (Table 2¹⁷).

Symptoms of DP can persist for months to years. Patients who fully recovered experienced a median duration of 0.5 years until symptom resolution, compared to incompletely recovered patients, who took approximately 1 year.¹⁸ Primary DP has slower improvement rates compared to secondary DP, with the median onset of effects occurring at Week 1.5 and peak improvements occurring at Week 6.¹⁶

OUTCOME Continued ED visits

Unfortunately, Mr. H does not follow through with his outpatient psychiatry appointments. In the 7 months following discharge, he visits the ED 8 times for alcohol intoxication, alcohol withdrawal, and methamphetamine abuse, in addition to 2 admissions for inpatient detoxification, during which he was still receiving the same scheduled medications (haloperidol 15 mg/d and quetiapine 200 mg/d). At each of his ED visits, there was no documentation of DP symptoms, which suggests his symptoms may have resolved.

Bottom Line

Because delusional parasitosis symptoms feel real to patients, it is crucial to build rapport to recommend and successfully initiate treatment. After ruling out nonpsychiatric etiologies, consider traditional treatment with antipsychotics, and consider medications for relief of pruritus or pain.

Related Resources

• Sellman D, Phan SV, Inyang M. Bugs on her skin—but nobody else sees them. Current Psychiatry. 2018;17(8):48,50-53.
• Campbell EH, Elston DM, Hawthorne JD, et al. Diagnosis and management of delusional parasitosis. J Am Acad Dermatol. 2019;80(5):1428-1434. doi:10.1016/j.jaad.2018.12.012

Drug Brand Names

Buprenorphine/naloxone • Suboxone
Haloperidol • Haldol
Hydroxyzine • Vistaril
Lithium • Eskalith, Lithobid
Methylphenidate • Concerta
Olanzapine • Zyprexa
Permethrin • Elimite
Phenobarbital • Solfoton, Tedral, Luminal
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Sertraline • Zoloft
Valproic acid • Depakote