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md:justify-between"><div class="flex flex-col xs:flex-row"><p class="mr-1 self-start">Author(s):</p><div class="flex flex-col xs:flex-row mb-3 md:mb-0"><div class="flex flex-wrap"><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/sara-robinson-msn-rn-pmhnp-bc">Sara Robinson, DNP, RN, PMHNP-BC</a><span class="mx-1">,</span></span><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/adriane-apicelli-msw">Adriane Apicelli, MSW</a></span></div><button class="text-xs text-gray-500 flex items-center mt-2 xs:mt-0 xs:ml-2">+1 More<span class="ml-1"><svg stroke="currentColor" fill="currentColor" stroke-width="0" viewBox="0 0 512 512" height="1em" width="1em" xmlns="http://www.w3.org/2000/svg"><path d="M256 294.1L383 167c9.4-9.4 24.6-9.4 33.9 0s9.3 24.6 0 34L273 345c-9.1 9.1-23.7 9.3-33.1.7L95 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class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">30% to 60% of individuals seeking treatment for SUD also meet criteria for PTSD.</p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class="flex justify-center"><div style="width:30%;float:;max-width:525px;margin:0 auto 1rem;clear:both;cursor:pointer" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%278000%27%20height=%275333%27/%3e"/></span><img alt="comorbid " title="comorbid " src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="comorbid " title="comorbid " srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F258b8392cd26c1564bd72b1a1c91c270c1f67ce5-8000x5333.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 1x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F258b8392cd26c1564bd72b1a1c91c270c1f67ce5-8000x5333.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div id="image-caption" class="text-gray-500 italic"><div class="blockText_blockContent__TbCXh"><p class="pb-2">Leigh Prather/AdobeStock</p></div></div><div class="top-[-100%] block w-[1px] transition-opacity duration-500 ease-in-out opacity-0 overflow-hidden"><img class="m-auto absolute inset-0 max-w-[0%] max-h-[0%] border-[3px] border-solid border-white shadow-[0px_0px_8px_rgba(0,0,0,0.3)] box-border transition ease-in-out duration-500" src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/258b8392cd26c1564bd72b1a1c91c270c1f67ce5-8000x5333.jpg?fit=crop&auto=format"/></div></div><style> #image-caption p{ font-size: 12px; max-width: 525px; margin: 0 auto; text-align: center; } </style></div><p class="pb-2"><strong>SPECIAL REPORT: COMORBIDITIES PART 2</strong></p><p class="pb-2">The experience of <a target="_blank" href="https://www.psychiatrictimes.com/view/the-psychosocial-impacts-of-war-and-armed-conflict-on-children">trauma</a> is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.<sup class="text-inherit">1</sup> The most prevalent comorbid disorders among adults with <a target="_blank" href="https://www.psychiatrictimes.com/view/integrating-digital-therapeutics-into-care-of-serious-mental-illness">serious mental illness</a> (SMI) are substance use disorders (SUDs).<sup class="text-inherit">2</sup> Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for <a target="_blank" href="https://www.psychiatrictimes.com/view/ptsds-long-reach">posttraumatic stress disorder</a> (PTSD).<sup class="text-inherit">3</sup> Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as <a target="_blank" href="https://www.psychiatrictimes.com/view/psychiatric-comorbidities-in-epilepsy-implications-for-clinical-practice">psychiatric comorbidities</a> is inadequate to capture the range of symptoms and impairments of this diverse patient population.<sup class="text-inherit">2</sup> Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.</p><article class="float-none w-auto my-4 p-4 bg-[#eee] md:clear-both md:float-right md:w-[40%] md:p-4 md:mt-0 md:mb-4 md:ml-4"><div><h3 class="text-xl mb-3 font-medium">Also In This Special Report</h3><div class="blockText_blockContent__TbCXh"><h4 class="text-lg pb-4 pt-2">Part 1</h4><p class="pb-2"><a target="_blank" href="https://www.psychiatrictimes.com/view/a-simple-concept-with-complex-implications"><strong>A Simple Concept With Complex Implications</strong></a></p><p class="pb-2">Daniel C. McFarland, DO; Luigi Grassi, MD; Michelle Riba, MD, MS, DFAPA, FAPM</p><p class="pb-2"></p><p class="pb-2"><a target="_blank" href="https://www.psychiatrictimes.com/view/helping-patients-with-attentional-difficulties-and-maladaptive-use-of-psychoactive-substances"><strong>Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances</strong></a></p><p class="pb-2">Steve Adelman, MD</p><p class="pb-2"></p><p class="pb-2"><a target="_blank" href="https://www.psychiatrictimes.com/view/new-directions-for-insomnia-and-bipolar-disorder"><strong>New Directions for Insomnia and Bipolar Disorder</strong></a></p><p class="pb-2">Chris Aiken, MD</p><p class="pb-2"></p><h4 class="text-lg pb-4 pt-2">Part 2</h4><p class="pb-2"><strong>Research Roundup: Psychiatric Comorbidities in the News </strong><br/>Leah Kuntz and Erin O’Brien</p><p class="pb-2"><br/></p></div></div></article><p class="pb-2">Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate <a target="_blank" href="https://www.psychiatrictimes.com/view/trauma-informed-care">trauma-informed care</a> (TIC) in both SUD and psychiatric settings,<sup class="text-inherit">4,5</sup> but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the <a target="_blank" href="https://www.psychiatrictimes.com/view/malingering-as-a-maladaptive-pattern-of-survival-during-the-pandemic">COVID-19 pandemic</a>,<sup class="text-inherit">6</sup> the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.</p><p class="pb-2">Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.<sup class="text-inherit">7</sup> Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.<sup class="text-inherit">8</sup> As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.</p><p class="pb-2"><strong>Integrate TIC and Substance Use Care</strong></p><p class="pb-2">There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.<sup class="text-inherit">1</sup> Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about <a target="_blank" href="https://www.psychiatrictimes.com/view/reflecting-on-trauma">patient trauma</a>.<sup class="text-inherit">5</sup> Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.<sup class="text-inherit">4</sup> Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.</p><p class="pb-2">Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased <a target="_blank" href="https://www.psychiatrictimes.com/view/ptsd-in-late-life-an-update-on-clinical-issues">PTSD symptom severity</a> is related to substance craving.<sup class="text-inherit">9</sup> Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.</p><p class="pb-2"><strong>Recognize Trauma as a Primary Pathway to Substance Use</strong></p><p class="pb-2">For decades, the pervasive narrative around <a target="_blank" href="https://www.psychiatrictimes.com/view/psychiatry-for-primary-care-an-update-on-substance-use-disorders-part-4-">substance use</a> was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.<sup class="text-inherit">10</sup> Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.<sup class="text-inherit">10</sup> Conversely, marijuana use has been associated with reductions in <a target="_blank" href="https://www.psychiatrictimes.com/view/report-finds-alarming-number-of-deaths-due-to-drug-overdose">opioid use</a> in states with medical cannabis use.<sup class="text-inherit">11</sup></p><p class="pb-2">Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.<sup class="text-inherit">12</sup> There is clearly an association between experiences of trauma and <a target="_blank" href="https://www.psychiatrictimes.com/view/stopping-the-opioid-crisis-evidence-based-public-health-approaches">substance use</a>, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.<sup class="text-inherit">9</sup> Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.<sup class="text-inherit">13</sup></p><p class="pb-2">One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.<sup class="text-inherit">2</sup> ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.<sup class="text-inherit">2</sup></p><p class="pb-2">As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.<sup class="text-inherit">14</sup> Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that <a target="_blank" href="https://www.psychiatrictimes.com/view/risk-of-overdose-with-antipsychotic-and-opioid-co-prescription">substance use</a> may have been the only accessible and available coping tool at that time.</p><p class="pb-2">When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and <a target="_blank" href="https://www.psychiatrictimes.com/view/investing-in-recovery-the-case-for-supporting-non-police-crisis-response">recovery</a>.</p><p class="pb-2"><strong>Partner With Patients Across Multiple Pathways to Recovery</strong></p><p class="pb-2">Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.</p><p class="pb-2">Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.<sup class="text-inherit">15</sup> Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.<sup class="text-inherit">16</sup> In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and <a target="_blank" href="https://www.psychiatrictimes.com/view/harnessing-harm-reduction-methods-to-combat-the-opioid-crisis">harm reduction</a> are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.<sup class="text-inherit">17</sup></p><p class="pb-2">Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.</p><p class="pb-2"><strong>Approach With Unconditional Positive Regard</strong></p><p class="pb-2">When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an <a target="_blank" href="https://www.psychiatrictimes.com/view/field-master-class-interviewing">art to facilitating an informative interview</a>. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.</p><p class="pb-2">Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.</p><p class="pb-2">Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.<sup class="text-inherit">18</sup> There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.</p><p class="pb-2"><strong>Engage in Ongoing Knowledge and Skill Development</strong></p><p class="pb-2">A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.<sup class="text-inherit">18</sup> Formal educational opportunities including fellowships in <a target="_blank" href="https://www.psychiatrictimes.com/view/want-to-do-this-for-baby-woes-of-pregnancy-addiction">addiction psychiatry</a>, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.<sup class="text-inherit">19</sup> All health care providers practicing clinically are required to participate in continuing education. Due to the <a target="_blank" href="https://www.psychiatrictimes.com/view/the-opioid-epidemic-is-alive-and-unwell">opioid epidemic</a>, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.</p><p class="pb-2">There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,<sup class="text-inherit">20</sup> which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.</p><p class="pb-2"><strong>Concluding Thoughts</strong></p><p class="pb-2">As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.</p><p class="pb-2"><strong>Mrs Robinson</strong> <em>is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.</em> <strong>Ms Apicelli</strong> <em>serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work.</em> <strong>Dr Nolte</strong> <em>is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.</em></p><p class="pb-2"><strong>References</strong></p><p class="pb-2">1. Coyle L, Hanna D, Dyer KFW, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/30714791/">Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review.</a> <em>Psychol Trauma.</em> 2019;11(7):802-809.</p><p class="pb-2">2. Integrated treatment for co-occurring disorders. Substance Abuse and Mental Health Services Administration. 2009. Accessed January 7, 2022. <a rel="nofollow noreferrer noopener" target="_blank" href="https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf">https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf</a></p><p class="pb-2">3. Rasmussen IS, Arefjord K, Winje D, Dovran A.<a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/30034641/"> Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment.</a> <em>Eur J Psychotraumatol.</em> 2018;9(1):1492835.</p><p class="pb-2">4. Mihelicova M, Brown M, Shuman V. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/29266247/">Trauma-informed care for individuals with serious mental illness: an avenue for community psychology’s involvement in community mental health.</a> <em>Am J Community Psychol.</em> 2018;61(1-2):141-152.</p><p class="pb-2">5. Beckett P, Holmes D, Phipps M, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/28840930/">Trauma-informed care and practice: practice improvement strategies in an inpatient mental health ward.</a> <em>J Psychosoc Nurs Ment Health Serv.</em> 2017;55(10):34-38.</p><p class="pb-2">6. Pfefferbaum B, North CS. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/32283003/">Mental health and the Covid-19 pandemic.</a> <em>N Engl J Med.</em> 2020;383(6):510-512.</p><p class="pb-2">7. Chessen CE, Comtois KA, Landes SJ. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/21969647/">Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology.</a> <em>Psychiatr Serv.</em> 2011;62(10):1201-1206.</p><p class="pb-2">8. Brunette MF, Oslin DW, Dixon LB, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/31500545/">The opioid epidemic and psychiatry: the time for action is now.</a> <em>Psychiatr Serv.</em> 2019;70(12):1168-1171.</p><p class="pb-2">9. McCauley JL, Killeen T, Gros DF, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/24179316/">Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment.</a> <em>Clin Psychol (New York).</em> 2012;19(3):283-304.</p><p class="pb-2">10. Nöel W, Wang J. Is cannabis a gateway drug? Key findings and literature review. National Institute of Justice. 2018. Accessed January 7, 2022. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.ojp.gov/pdffiles1/nij/252950.pdf">https://www.ojp.gov/pdffiles1/nij/252950.pdf</a></p><p class="pb-2">11. Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/29610897/">Association between US state medical cannabis laws and opioid prescribing in the Medicare part D population.</a> <em>JAMA Intern Med.</em> 2018;178(5):667-672.</p><p class="pb-2">12. Degenhardt L, Dierker L, Chiu WT, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/20060657/">Evaluating the drug use “gateway” theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys.</a> <em>Drug Alcohol Depend.</em> 2010;108(1-2):84-97.</p><p class="pb-2">13. Nolte K, Drew AL, Friedmann PD, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/32947174/">Opioid initiation and injection transition in rural northern New England: a mixed-methods approach.</a> <em>Drug Alcohol Depend.</em> 2020;217:108256.</p><p class="pb-2">14. Lederhos Smith C, Severtsen B, Vandermause R, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/29935910/">Seeking chronic pain relief: a hermeneutic exploration.</a> Pain Manag Nurs. 2018;19(6):652-662.</p><p class="pb-2">15. Henwood BF, Padgett DK, Tiderington E. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/23404076/">Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults.</a> <em>J Behav Health Serv Res.</em> 2014;41(1):80-89.</p><p class="pb-2">16. Kelly JF, White WL. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.tandfonline.com/doi/abs/10.1080/1556035X.2012.705646">Broadening the base of addiction mutual-help organizations.</a> <em>J Groups Addiction Recovery.</em> 2012;7(2-4):82-101.</p><p class="pb-2">17. Carver H, Ring N, Miler J, Parkes T. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/32005119/">What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography.</a> <em>Harm Reduct J.</em> 2020;17(1):10.</p><p class="pb-2">18. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/23490450/">Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.</a> <em>Drug Alcohol Depend.</em> 2013;131(1-2):23-35.</p><p class="pb-2">19. Galanter M. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/32902052/">The development of fellowship training in addiction psychiatry.</a> <em>Am J Addict.</em> 2020;29(5):378-382.</p><p class="pb-2">20. Salvador J, Bhatt S, Fowler R, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/31434561/">Engagement with Project ECHO to increase medication-assisted treatment in rural primary care.</a> <em>Psychiatr Serv.</em> 2019;70(12):1157-1160. ❒</p><p class="pb-2"><br/></p><p class="pb-2"></p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"><div class="flex sm:inline"><a target="_blank" class="mr-[5px] md:mr-2 p-[.56rem] border rounded-md bg-primary text-white" href="https://cdn.sanity.io/files/0vv8moc6/psychtimes/8ce6e5ee0ca3901f596531afbc11db4153c87ea0.pdf/PSY0322_Ezine_v2.pdf">Download Issue PDF</a></div></div><div class="mb-6"><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 pl-2 -ml-6 xs:ml-0 w-screen xs:w-full mb-4 "><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="jsx-19ede9f0a5a45918 text-white text-2xl md:text-3xl pb-2 md:pb-1">Articles in this issue</div><hr class="jsx-19ede9f0a5a45918 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href="/view/teenagers-substance-use?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex md:hidden justify-center items-center"></div><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 gap-x-4"><a class="jsx-ad50481d5ee26850" href="/view/beyond-abstinence-other-clinically-meaningful-endpoints-for-patients-with-substance-use-disorders?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/4986d2c1baf0814ec6a84715061ad53397e0883d-1600x900.png?fit=crop&auto=format" alt="F. 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Clayton, MD</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/maternal-mental-health-life-cycle?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 gap-x-4"><a class="jsx-ad50481d5ee26850" href="/view/coping-with-diagnostic-uncertainty-in-mixed-states-comparing-treatment-risks?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/7466224b747025da7c84318fef9678a0f34e2c49-3673x2960.jpg?fit=crop&auto=format" alt="bipolar" width="288" class="jsx-ad50481d5ee26850 lg:w-[110px] lg:h-[100px] xl:w-[135px] xl:h-[125px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full xl:w-[70%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 26th 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/coping-with-diagnostic-uncertainty-in-mixed-states-comparing-treatment-risks?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent">Coping with Diagnostic Uncertainty in Mixed States: Comparing Treatment Risks</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/james-phelps-md">James Phelps, MD</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/coping-with-diagnostic-uncertainty-in-mixed-states-comparing-treatment-risks?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div><div class="jsx-ad50481d5ee26850 w-full h-full"><div class="jsx-ad50481d5ee26850 flex flex-col sm:flex-row justify-between my-4 gap-x-4"><a class="jsx-ad50481d5ee26850" href="/view/malingering-in-the-forensic-and-correctional-settings?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"><img src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/d83dbdbc3902e16c8b0970cd5584988f4f9c4852-3092x2019.jpg?fit=crop&auto=format" alt="forensic psychiatry" width="288" class="jsx-ad50481d5ee26850 lg:w-[110px] lg:h-[100px] xl:w-[135px] xl:h-[125px] xs:w-[288px] "/></a><div class="jsx-ad50481d5ee26850 article-detail flex flex-col gap-[0.2rem] w-full xl:w-[70%]"><span class="jsx-ad50481d5ee26850 article-publish-date block italic text-sm text-gray-500 mt-[1rem] sm:mt-0">November 21st 2024</span><p class="jsx-ad50481d5ee26850 article-title font-bold text-[1rem]"><a class="jsx-ad50481d5ee26850" href="/view/malingering-in-the-forensic-and-correctional-settings?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent">Malingering in the Forensic and Correctional Settings</a></p><div class="jsx-ad50481d5ee26850 authors flex-row wrap gap-[0.2rem]"><a class="jsx-ad50481d5ee26850 text-[#00ADEF] underline text-sm italic" href="/authors/vikram-kumar-md">Vikram Kumar, MD</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/malingering-in-the-forensic-and-correctional-settings?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="pb-24"></div></div><script type="application/ld+json">{"@context":"https://schema.org","@type":"NewsArticle","headline":"Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder","datePublished":"2022-03-21T14:30:00.000Z","dateModified":"2022-03-21T14:39:42Z","inLanguage":"en-US","image":"https://cdn.sanity.io/images/0vv8moc6/psychtimes/258b8392cd26c1564bd72b1a1c91c270c1f67ce5-8000x5333.jpg?fit=crop&auto=format","mainEntityOfPage":{"@type":"WebPage","@id":"https://www.psychiatrictimes.com/view/supporting-patients-with-serious-mental-illness-and-comorbid-substance-use-disorder-and-posttraumatic-stress-disorder"},"publisher":{"@type":"Organization","name":"Psychiatric Times","logo":{"@type":"ImageObject","url":"https://www.psychiatrictimes.com/PsychiatricTimesLogo.png"}},"keywords":"special report,ptsd,substance use,substance use disorder,serious mental illness ,comorbid,comorbidities","articleBody":"\n\nSPECIAL REPORT: COMORBIDITIES PART 2\n\nThe experience of trauma is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.1 The most prevalent comorbid disorders among adults with serious mental illness (SMI) are substance use disorders (SUDs).2 Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for posttraumatic stress disorder (PTSD).3 Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as psychiatric comorbidities is inadequate to capture the range of symptoms and impairments of this diverse patient population.2 Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.\n\n\n\nEvidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate trauma-informed care (TIC) in both SUD and psychiatric settings,4,5 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the COVID-19 pandemic,6 the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.\n\nTreatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.7 Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.8 As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.\n\nIntegrate TIC and Substance Use Care\n\nThere is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.1 Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about patient trauma.5 Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.4 Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.\n\nSimilarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased PTSD symptom severity is related to substance craving.9 Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.\n\nRecognize Trauma as a Primary Pathway to Substance Use\n\nFor decades, the pervasive narrative around substance use was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.10 Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.10 Conversely, marijuana use has been associated with reductions in opioid use in states with medical cannabis use.11\n\nDrug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.12 There is clearly an association between experiences of trauma and substance use, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.9 Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.13\n\nOne notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.2 ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.2\n\nAs we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.14 Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that substance use may have been the only accessible and available coping tool at that time.\n\nWhen we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and recovery.\n\nPartner With Patients Across Multiple Pathways to Recovery\n\nSubstance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.\n\nAbstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.15 Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.16 In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and harm reduction are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.17\n\nInstead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.\n\nApproach With Unconditional Positive Regard\n\nWhen assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an art to facilitating an informative interview. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.\n\nApproaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.\n\nOngoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.18 There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.\n\nEngage in Ongoing Knowledge and Skill Development\n\nA systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.18 Formal educational opportunities including fellowships in addiction psychiatry, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.19 All health care providers practicing clinically are required to participate in continuing education. Due to the opioid epidemic, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.\n\nThere are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,20 which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.\n\nConcluding Thoughts\n\nAs psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.\n\nMrs Robinson is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham. Ms Apicelli serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work. Dr Nolte is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.\n\nReferences\n\n1. Coyle L, Hanna D, Dyer KFW, et al. Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review. Psychol Trauma. 2019;11(7):802-809.\n\n2. Integrated treatment for co-occurring disorders. Substance Abuse and Mental Health Services Administration. 2009. Accessed January 7, 2022. https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf\n\n3. Rasmussen IS, Arefjord K, Winje D, Dovran A. Childhood maltreatment trauma: a comparison between patients in treatment for substance use disorders and patients in mental health treatment. Eur J Psychotraumatol. 2018;9(1):1492835.\n\n4. Mihelicova M, Brown M, Shuman V. Trauma-informed care for individuals with serious mental illness: an avenue for community psychology’s involvement in community mental health. Am J Community Psychol. 2018;61(1-2):141-152.\n\n5. Beckett P, Holmes D, Phipps M, et al. Trauma-informed care and practice: practice improvement strategies in an inpatient mental health ward. J Psychosoc Nurs Ment Health Serv. 2017;55(10):34-38.\n\n6. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020;383(6):510-512.\n\n7. Chessen CE, Comtois KA, Landes SJ. Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology. Psychiatr Serv. 2011;62(10):1201-1206.\n\n8. Brunette MF, Oslin DW, Dixon LB, et al. The opioid epidemic and psychiatry: the time for action is now. Psychiatr Serv. 2019;70(12):1168-1171.\n\n9. McCauley JL, Killeen T, Gros DF, et al. Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment. Clin Psychol (New York). 2012;19(3):283-304.\n\n10. Nöel W, Wang J. Is cannabis a gateway drug? Key findings and literature review. National Institute of Justice. 2018. Accessed January 7, 2022. https://www.ojp.gov/pdffiles1/nij/252950.pdf\n\n11. Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. Association between US state medical cannabis laws and opioid prescribing in the Medicare part D population. JAMA Intern Med. 2018;178(5):667-672.\n\n12. Degenhardt L, Dierker L, Chiu WT, et al. Evaluating the drug use “gateway” theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug Alcohol Depend. 2010;108(1-2):84-97.\n\n13. Nolte K, Drew AL, Friedmann PD, et al. Opioid initiation and injection transition in rural northern New England: a mixed-methods approach. Drug Alcohol Depend. 2020;217:108256.\n\n14. Lederhos Smith C, Severtsen B, Vandermause R, et al. Seeking chronic pain relief: a hermeneutic exploration. Pain Manag Nurs. 2018;19(6):652-662.\n\n15. Henwood BF, Padgett DK, Tiderington E. Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. J Behav Health Serv Res. 2014;41(1):80-89.\n\n16. Kelly JF, White WL. Broadening the base of addiction mutual-help organizations. J Groups Addiction Recovery. 2012;7(2-4):82-101.\n\n17. Carver H, Ring N, Miler J, Parkes T. What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography. Harm Reduct J. 2020;17(1):10.\n\n18. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35.\n\n19. Galanter M. The development of fellowship training in addiction psychiatry. Am J Addict. 2020;29(5):378-382.\n\n20. Salvador J, Bhatt S, Fowler R, et al. Engagement with Project ECHO to increase medication-assisted treatment in rural primary care. Psychiatr Serv. 2019;70(12):1157-1160. ❒\n\n\n\n\n","description":"30% to 60% of individuals seeking treatment for SUD also meet criteria for PTSD.","author":[{"@type":"Person","name":"Sara Robinson, DNP, RN, PMHNP-BC"},{"@type":"Person","name":"Adriane Apicelli, MSW"},{"@type":"Person","name":"Kerry Nolte, PhD, FNP-C"}]}</script></div></div><div class="flex-none w-[300px] z-[9999] relative hidden md:block"><div style="top:5rem" class="sticky custom-spacing"><div class="collapse-container " style="overflow:hidden;max-height:900px;transition:max-height .4s ease-in-out"></div></div></div></div><div id="div-gpt-ad-pixel" style="width:1px;height:1px" class=""></div><noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-5V9L5PL" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><div id="footerOuterWrap" class="w-full bg-primary flex flex-col items-center justify-center"><div class="container w-[1340px]"><div id="footerInnerWrap" 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presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.","_key":"2eb0d51c51dd","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"1","_key":"2a6675d2cc21"},{"_type":"span","marks":[],"text":" The most prevalent comorbid disorders among adults with ","_key":"4a2d433bf50d"},{"_type":"span","marks":["0beb062424a1"],"text":"serious mental illness","_key":"8ca33cd9d732"},{"_type":"span","marks":[],"text":" (SMI) are substance use disorders (SUDs).","_key":"838c95c29a33"},{"_type":"span","marks":["superscript"],"text":"2","_key":"ee5c0e12499c"},{"text":" Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for ","_key":"b98ddf5cc7cb","_type":"span","marks":[]},{"_type":"span","marks":["2391c8da5a78"],"text":"posttraumatic stress disorder","_key":"8d50f8cf4ce3"},{"marks":[],"text":" (PTSD).","_key":"01349bf9c637","_type":"span"},{"text":"3","_key":"bac69b3ae4b2","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as ","_key":"e0e5d65b05a1"},{"_key":"10543fb36ea4","_type":"span","marks":["cdbc6df4df75"],"text":"psychiatric comorbidities"},{"_type":"span","marks":[],"text":" is inadequate to capture the range of symptoms and impairments of this diverse patient population.","_key":"d05d9b370dd7"},{"_type":"span","marks":["superscript"],"text":"2","_key":"4e22bf8af208"},{"_type":"span","marks":[],"text":" Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.","_key":"65fe5125142a"}],"_type":"block","style":"normal","_key":"6e9dc0f1ba4c","upload_doc":null,"uploadAudio":null,"medias":null},{"uploadAudio":null,"medias":null,"_type":"sidebar","caption":"Also In This Special Report","_key":"92b61cfdbf2f","content":[{"_type":"block","style":"h4","_key":"efee3fe5515a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Part 1","_key":"e0d29e77deb9"}]},{"_key":"d8c560ca1431","markDefs":[{"href":"https://www.psychiatrictimes.com/view/a-simple-concept-with-complex-implications","_key":"b014dd0e1d31","blank":true,"_type":"link"}],"children":[{"marks":["b014dd0e1d31","strong"],"text":"A Simple Concept With Complex Implications","_key":"60d1782c33630","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Daniel C. McFarland, DO; Luigi Grassi, MD; Michelle Riba, MD, MS, DFAPA, FAPM","_key":"a7a1084fdfd20"}],"_type":"block","style":"normal","_key":"38d2363b29a9"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9a0bee1b389f0"}],"_type":"block","style":"normal","_key":"25816654a2af"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/helping-patients-with-attentional-difficulties-and-maladaptive-use-of-psychoactive-substances","_key":"79c9b9229d14"}],"children":[{"_type":"span","marks":["79c9b9229d14","strong"],"text":"Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances","_key":"667d6aa6682b0"}],"_type":"block","style":"normal","_key":"65e3e8845a52"},{"children":[{"_type":"span","marks":[],"text":"Steve Adelman, MD","_key":"e43849d8face0"}],"_type":"block","style":"normal","_key":"a330a4e2e6f2","markDefs":[]},{"children":[{"_key":"b45761b05d92","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"b592f35a66f7","markDefs":[]},{"children":[{"_type":"span","marks":["547094e95426","strong"],"text":"New Directions for Insomnia and Bipolar Disorder","_key":"bb4f0d76150a0"}],"_type":"block","style":"normal","_key":"2e18bcb0d935","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/new-directions-for-insomnia-and-bipolar-disorder","_key":"547094e95426"}]},{"children":[{"_type":"span","marks":[],"text":"Chris Aiken, MD","_key":"1bb49b2d90c60"}],"_type":"block","style":"normal","_key":"2b7ec25b5b34","markDefs":[]},{"_key":"58ea29c3a32c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"2cde975bf65f"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Part 2","_key":"16392822f4ca"}],"_type":"block","style":"h4","_key":"520767305dc7"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Research Roundup: Psychiatric Comorbidities in the News ","_key":"3b2fb0ae65a90"},{"marks":[],"text":"\nLeah Kuntz and Erin O’Brien","_key":"5f359d984353","_type":"span"}],"_type":"block","style":"normal","_key":"892e48a4ca0a"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"\n","_key":"bcee5589cd180"}],"_type":"block","style":"normal","_key":"edbb07752270"}],"upload_doc":null},{"children":[{"_key":"2f515de818e20","_type":"span","marks":[],"text":"Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate "},{"_type":"span","marks":["ef5d68ef9750"],"text":"trauma-informed care","_key":"17f565e3bb82"},{"_type":"span","marks":[],"text":" (TIC) in both SUD and psychiatric settings,","_key":"f7669cf08b3e"},{"_type":"span","marks":["superscript"],"text":"4,5","_key":"4a380f2e54ec"},{"_type":"span","marks":[],"text":" but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the ","_key":"3ad2932b7372"},{"_type":"span","marks":["34129d136172"],"text":"COVID-19 pandemic","_key":"68269f9a10d7"},{"marks":[],"text":",","_key":"6796dce3f2d6","_type":"span"},{"_type":"span","marks":["superscript"],"text":"6","_key":"d62875f833d6"},{"_type":"span","marks":[],"text":" the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.","_key":"a38c2bbb88c5"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"ba80900ac8cf","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/trauma-informed-care","_key":"ef5d68ef9750"},{"_type":"link","href":"https://www.psychiatrictimes.com/view/malingering-as-a-maladaptive-pattern-of-survival-during-the-pandemic","_key":"34129d136172","nofollow":true,"blank":true}]},{"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.","_key":"c1f474c6c5c80"},{"_type":"span","marks":["superscript"],"text":"7","_key":"15ee35970ee4"},{"_key":"e783cd9127fd","_type":"span","marks":[],"text":" Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers."},{"_type":"span","marks":["superscript"],"text":"8","_key":"2476bd6bd6f5"},{"text":" As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.","_key":"83579ae3fef9","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"539d8d1f84fb","upload_doc":null},{"markDefs":[],"children":[{"text":"Integrate TIC and Substance Use Care","_key":"a38f9db42d8b0","_type":"span","marks":["strong"]}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"45979fc339b6"},{"style":"normal","_key":"a61f89561fb3","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/reflecting-on-trauma","_key":"552c51bd7486"}],"children":[{"_type":"span","marks":[],"text":"There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.","_key":"efe0a8ecd1fc0"},{"_type":"span","marks":["superscript"],"text":"1","_key":"77d525110661"},{"_type":"span","marks":[],"text":" Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about ","_key":"f6beb01b34f7"},{"_type":"span","marks":["552c51bd7486"],"text":"patient trauma","_key":"87b02f8a5583"},{"_type":"span","marks":[],"text":".","_key":"df0d99e0804c"},{"_key":"3f162fbf0ee0","_type":"span","marks":["superscript"],"text":"5"},{"_type":"span","marks":[],"text":" Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.","_key":"097c30c55140"},{"marks":["superscript"],"text":"4","_key":"12c93d1d0a7d","_type":"span"},{"_key":"26ea01c5c9ea","_type":"span","marks":[],"text":" Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment."}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block"},{"uploadAudio":null,"medias":null,"_key":"60cb9755e5f4","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/ptsd-in-late-life-an-update-on-clinical-issues","_key":"5c50859e82ed","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased ","_key":"02ff9cea03220"},{"_type":"span","marks":["5c50859e82ed"],"text":"PTSD symptom severity","_key":"3eb8d3d16bb8"},{"marks":[],"text":" is related to substance craving.","_key":"f95e6266968d","_type":"span"},{"_type":"span","marks":["superscript"],"text":"9","_key":"6cfd13196ea7"},{"_type":"span","marks":[],"text":" Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.","_key":"05acf3be8809"}],"_type":"block","style":"normal","upload_doc":null},{"markDefs":[],"children":[{"_key":"f3fa0175b0280","_type":"span","marks":["strong"],"text":"Recognize Trauma as a Primary Pathway to Substance Use"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"c1ff148baf27"},{"style":"normal","_key":"623641b02eb6","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/psychiatry-for-primary-care-an-update-on-substance-use-disorders-part-4-","_key":"bf8e7a568398"},{"_key":"3505b46bc602","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/report-finds-alarming-number-of-deaths-due-to-drug-overdose"}],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_key":"0a13b6ff0a8b0","_type":"span","marks":[],"text":"For decades, the pervasive narrative around "},{"_type":"span","marks":["bf8e7a568398"],"text":"substance use","_key":"8fc5d08fc729"},{"_type":"span","marks":[],"text":" was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.","_key":"e77dd7874859"},{"_type":"span","marks":["superscript"],"text":"10","_key":"8a7572734778"},{"marks":[],"text":" Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.","_key":"b2f200c075e4","_type":"span"},{"_type":"span","marks":["superscript"],"text":"10","_key":"0c14905888cd"},{"_key":"d7fdabd06488","_type":"span","marks":[],"text":" Conversely, marijuana use has been associated with reductions in "},{"_type":"span","marks":["3505b46bc602"],"text":"opioid use","_key":"445778bba4fe"},{"marks":[],"text":" in states with medical cannabis use.","_key":"257390ae0ee2","_type":"span"},{"text":"11","_key":"b727832288ca","_type":"span","marks":["superscript"]}],"_type":"block"},{"children":[{"_key":"b9bfc22b97510","_type":"span","marks":[],"text":"Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance."},{"_type":"span","marks":["superscript"],"text":"12","_key":"35acfbd24ab4"},{"_type":"span","marks":[],"text":" There is clearly an association between experiences of trauma and ","_key":"f22e087ca494"},{"_key":"7b08959518bf","_type":"span","marks":["67ddc1df79d5"],"text":"substance use"},{"_type":"span","marks":[],"text":", as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.","_key":"4e292d9b31ad"},{"_type":"span","marks":["superscript"],"text":"9","_key":"b14f87ac3df2"},{"marks":[],"text":" Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.","_key":"220e303548c7","_type":"span"},{"marks":["superscript"],"text":"13","_key":"d13ae3a6abb2","_type":"span"}],"_type":"block","style":"normal","_key":"ab255408fca2","markDefs":[{"_key":"67ddc1df79d5","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/stopping-the-opioid-crisis-evidence-based-public-health-approaches"}],"upload_doc":null,"uploadAudio":null,"medias":null},{"style":"normal","_key":"020e84836837","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.","_key":"d281497673970","_type":"span"},{"_type":"span","marks":["superscript"],"text":"2","_key":"561448aac89f"},{"_type":"span","marks":[],"text":" ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.","_key":"03ec5adccc8a"},{"_type":"span","marks":["superscript"],"text":"2","_key":"9bb6ea436471"}],"_type":"block"},{"medias":null,"children":[{"_type":"span","marks":[],"text":"As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.","_key":"4202aa35e4c40"},{"_type":"span","marks":["superscript"],"text":"14","_key":"83e6524c0127"},{"_type":"span","marks":[],"text":" Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that ","_key":"ef5c21ab8d3f"},{"_key":"7e2d0cd75571","_type":"span","marks":["906b00192875"],"text":"substance use"},{"_key":"8280d27fedd9","_type":"span","marks":[],"text":" may have been the only accessible and available coping tool at that time."}],"_type":"block","style":"normal","_key":"75288a41a071","markDefs":[{"href":"https://www.psychiatrictimes.com/view/risk-of-overdose-with-antipsychotic-and-opioid-co-prescription","_key":"906b00192875","nofollow":true,"blank":true,"_type":"link"}],"upload_doc":null,"uploadAudio":null},{"_key":"dc2946d5b637","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/investing-in-recovery-the-case-for-supporting-non-police-crisis-response","_key":"de9ff2dc985d"}],"children":[{"_key":"e5593d7be3b40","_type":"span","marks":[],"text":"When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and "},{"_type":"span","marks":["de9ff2dc985d"],"text":"recovery","_key":"eb2e1c28c0b4"},{"text":".","_key":"95b22b4fa047","_type":"span","marks":[]}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null},{"_key":"fef10ea8a5de","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Partner With Patients Across Multiple Pathways to Recovery","_key":"50deb45bfba40"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal"},{"uploadAudio":null,"medias":null,"_key":"d4eb1a47c415","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.","_key":"9e35a107e8740"}],"_type":"block","style":"normal","upload_doc":null},{"medias":null,"_type":"block","style":"normal","_key":"fb7a3b1ee203","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/harnessing-harm-reduction-methods-to-combat-the-opioid-crisis","_key":"897174545542","nofollow":true,"blank":true}],"children":[{"_type":"span","marks":[],"text":"Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.","_key":"55dc7e2f24070"},{"marks":["superscript"],"text":"15","_key":"6669442aa1d0","_type":"span"},{"_type":"span","marks":[],"text":" Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.","_key":"8bce0270ddab"},{"_type":"span","marks":["superscript"],"text":"16","_key":"72c7c1b0111e"},{"_type":"span","marks":[],"text":" In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and ","_key":"7709704badfb"},{"_type":"span","marks":["897174545542"],"text":"harm reduction","_key":"5bcdb9f2be3b"},{"_type":"span","marks":[],"text":" are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.","_key":"4d158036f005"},{"_type":"span","marks":["superscript"],"text":"17","_key":"ddaed74a48af"}],"upload_doc":null,"uploadAudio":null},{"uploadAudio":null,"medias":null,"_key":"cc5baba9c174","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.","_key":"41247345b98e0"}],"_type":"block","style":"normal","upload_doc":null},{"markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"text":"Approach With Unconditional Positive Regard","_key":"0bef4283c2a70","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"6e15fe9e4681"},{"_key":"c2d4538245e6","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[{"href":"https://www.psychiatrictimes.com/view/field-master-class-interviewing","_key":"802396cb3866","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an ","_key":"c4f31ef8c3100"},{"_type":"span","marks":["802396cb3866"],"text":"art to facilitating an informative interview","_key":"905801823c81"},{"marks":[],"text":". Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. 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Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space."}],"_type":"block"},{"_type":"block","style":"normal","_key":"ae9d1e603cc2","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":[],"text":"Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.","_key":"2cc339f442c60","_type":"span"},{"_type":"span","marks":["superscript"],"text":"18","_key":"1894c3b830c6"},{"_type":"span","marks":[],"text":" There are often inciting events for these views, and the outward expression is likely most often unintentional. 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It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.","_key":"5a6e5e41d21d"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"719bd5e740cf"},{"_type":"block","style":"normal","_key":"702b0ce2ac45","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"text":"There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,","_key":"adbb825779790","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"20","_key":"253e8f27f40a"},{"_type":"span","marks":[],"text":" which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.","_key":"fb3dac6ee469"}]},{"markDefs":[],"children":[{"text":"Concluding Thoughts","_key":"b8ced549652e0","_type":"span","marks":["strong"]}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"57bf5c19f54b"},{"medias":null,"children":[{"_type":"span","marks":[],"text":"As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. 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(This article will not focus on neonaticide—murder of the newborn at birth or in the first 24 hours of life","_key":"04259c4510e30"},{"_key":"d0696ba5931d","_type":"span","marks":["superscript"],"text":"1"},{"_type":"span","marks":[],"text":"—because it is a very different phenomenon than other maternal filicides.","_key":"c32577e21930"},{"_type":"span","marks":["superscript"],"text":"2","_key":"4a0ee3b45434"},{"marks":[],"text":" In some cases of child murder by the mother, psychiatrists may have a critical role in prevention.","_key":"7a579c4dbf30","_type":"span"}],"_type":"block","style":"normal","_key":"582a23a3b621"},{"_key":"83f13b84795d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In 1969, after reviewing the world literature, Phillip J. 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The 5 motives are (1) fatal maltreatment, (2) unwanted child, (3) partner revenge, (4) altruism, and (5) acute psychosis."},{"_type":"span","marks":["superscript"],"text":"7","_key":"6ed231196f1f"},{"_key":"5eab1ecbccb1","_type":"span","marks":[],"text":" Only sometimes is serious mental illness implicated."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"57c9f6ed59f00"}],"_type":"block","style":"normal","_key":"5280064bcd84"},{"style":"normal","_key":"356128bee077","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The 5 Motives","_key":"ced97ae355ba0"}],"_type":"block"},{"children":[{"text":"Fatal maltreatment occurs as the outcome of what is often chronic abuse or neglect. This is the most common type of child homicide by parents. There are likely many child deaths by fatal maltreatment that go undetected or remain unconfirmed, but the annual rate of confirmed child maltreatment deaths is 1 to 2 per 100,000 children in the US.8 Of those children, three-quarters are younger than 4 years.","_key":"cef704dd42bf0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"8","_key":"29bfbf48af44"},{"_type":"span","marks":[],"text":" Children with prior reports to child protective services were almost 6 times more likely to die from subsequent fatal maltreatment than children without prior reports.","_key":"f752870d83a1"},{"text":"9","_key":"9aba115e6b85","_type":"span","marks":["superscript"]},{"text":" Infants and children have presented to medical settings with non–life-threatening injuries such as unexplained bruises, with a lack of recognition that the injuries were likely from maltreatment, and have gone on to present later with signs of escalating abuse, including death. Such injuries have been termed ","_key":"1a44fb1860f2","_type":"span","marks":[]},{"marks":["em"],"text":"sentinel injuries","_key":"cef704dd42bf1","_type":"span"},{"_type":"span","marks":[],"text":", as they are clinical indicators of potentially adverse outcomes that warrant further inquiry.","_key":"cef704dd42bf2"},{"_type":"span","marks":["superscript"],"text":"10","_key":"b144a2ffe6e2"}],"_type":"block","style":"normal","_key":"356a12144a9a","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Fatal maltreatment incidents may begin with a caregiver poorly coping with their crying infant, becoming angry with their young child in the midst of feeding or toilet training issues, providing excessive corporal punishment for general disobedience, or becoming frustrated with their child with medical complexity or disability. Parents in fatal maltreatment cases may have mental illnesses, personality disorders, substance use disorders, or coping difficulties.","_key":"9fd6e6c926030"}],"_type":"block","style":"normal","_key":"928703e78f06"},{"_key":"1fe0983b7b2a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In unwanted child cases, mothers kill a child who is seen as a hindrance or is in the way of the mother’s goals. In partner revenge cases, the mother kills a child to emotionally wound the other parent. She may kill all her children or only the child perceived as the favorite of the other parent. This may occur in the context of a volatile breakup or custody battle. In both these motive categories, one may note personality disorders or attachment issues. These 2 types may seem the most difficult for others to grasp, but in these cases, the child is often seen as akin to property or a pawn rather than a person in their own right.","_key":"ecdf79ee16a80"}],"_type":"block","style":"normal"},{"style":"normal","_key":"7c63b43808c7","markDefs":[],"children":[{"marks":[],"text":"In altruistic maternal filicide cases, the mother kills the child out of love, often related to severe depression or psychosis. Some mothers with suicidal ideation believe they should kill their child as part of an extended suicide rather than leaving them motherless","_key":"77b79ae967b00","_type":"span"},{"marks":["superscript"],"text":"6","_key":"5d669bac183b","_type":"span"},{"_type":"span","marks":[],"text":"; others believe their child is otherwise facing a fate worse than death—such as being sold to a human trafficking organization—and believe a loving death is better for their child. Finally, in maternal filicide cases of rare acute psychosis, a mother experiencing psychosis may, for example, follow a command hallucination that she believes is God telling her to kill.","_key":"ad992aa5ff13"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"","_key":"197e5377b0e60"}],"_type":"block","style":"normal","_key":"acffb829715c","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"Diagnosis","_key":"eeb3e3aa9a6d0"}],"_type":"block","style":"normal","_key":"e7a932503195","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"Diagnostically, it is also important to discern the difference between an obsession in postpartum obsessive-compulsive disorder (ppOCD) and the delusions of postpartum psychosis. This can be tricky, as obsessions of child murder may be a presentation of ppOCD.","_key":"8abbffab39cd0"},{"text":"11","_key":"5beea44aebc1","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" ppOCD is much more common than postpartum psychosis, often presenting with worries or fears about the infant and attempts to neutralize the intrusive, unwanted, and distressing thoughts (such as accidentally putting the baby in a microwave or dropping the baby over a balcony) with compulsions or avoidance of the infant.","_key":"d589134e128c"},{"_type":"span","marks":["superscript"],"text":"12","_key":"59bf974ac808"}],"_type":"block","style":"normal","_key":"a565a98c3a6f","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"In contrast with ppOCD, postpartum psychosis is generally considered a medical emergency, necessitating hospitalization related to its rapid evolution, severe symptoms, and elevated risk of both infanticide and suicide.","_key":"4192d1072c880","_type":"span"},{"_type":"span","marks":["superscript"],"text":"13","_key":"7458890d8e36"},{"_type":"span","marks":[],"text":" Mothers may have delusions about the infant and may experience commanding auditory hallucinations. It can be critical to determine whether a mother has developed delusions about her baby (such as those occurring in postpartum psychosis or severe depression), as these may significantly increase the risk, such as if they are delusions that the baby is evil.","_key":"bb899ad937d8"},{"_type":"span","marks":["superscript"],"text":"14","_key":"ac2f2d1770da"}],"_type":"block","style":"normal","_key":"a28c65f2dfb2"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"However, recent evidence indicates that when mental illness is treated, the risk of parents harming their child decreases.","_key":"14a141defccb0"},{"_type":"span","marks":["superscript"],"text":"15,16","_key":"9fd98f011dc7"},{"_type":"span","marks":[],"text":" This is similar to how mental illness symptoms are considered dynamic risk factors for other types of violence.","_key":"7c8810816278"}],"_type":"block","style":"normal","_key":"8eadde9f3ec1"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"f1e61a68df040"}],"_type":"block","style":"normal","_key":"49dab4ac508d"},{"children":[{"marks":["strong"],"text":"Prevention","_key":"a9f75cba597b0","_type":"span"}],"_type":"block","style":"normal","_key":"5e05030c5a0e","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"In considering prevention, psychiatrists should feel comfortable inquiring about maternal filicidal thoughts, though many do not.","_key":"040f64a54fb80"},{"_key":"a0411bc3103f","_type":"span","marks":["superscript"],"text":"17"},{"_type":"span","marks":[],"text":" One way to begin asking about such thoughts is as they relate to suicide. For example, one may ask a mother expressing suicidal thoughts what she thinks would happen to her child should she die by suicide. This can yield useful information. Another avenue of inquiry is to ask a mother about her thoughts of frustration with the child and how she copes with these.","_key":"d067440234d4"}],"_type":"block","style":"normal","_key":"3a58ac470498","markDefs":[]},{"children":[{"marks":[],"text":"Mothers who have filicidal thoughts may feel more comfortable disclosing suicidal thoughts to mental health clinicians in order to get help.","_key":"b62a60bdfa210","_type":"span"},{"_type":"span","marks":["superscript"],"text":"18","_key":"59ef87c6049e"},{"text":" Mothers with depression or psychosis may experience filicidal thoughts,","_key":"adc69d6941fc","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"19","_key":"fd4b9d680f98"},{"_type":"span","marks":[],"text":" but mothers who are stressed may also experience them—for example, those with a colicky infant.","_key":"55a137d66433"},{"_type":"span","marks":["superscript"],"text":"20","_key":"4271ef791ce9"}],"_type":"block","style":"normal","_key":"43a31e81b6b3","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"","_key":"cc1a3af7ebe10"}],"_type":"block","style":"normal","_key":"c707495c1dff","markDefs":[]},{"style":"normal","_key":"a95356f65f12","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Child Fatality Review Teams","_key":"cad00c35e0740"}],"_type":"block"},{"children":[{"marks":[],"text":"On a public health level, psychiatrists can be valuable members of their local county child fatality review teams (CFRs).","_key":"cfe0fdf4a7a20","_type":"span"},{"_type":"span","marks":["superscript"],"text":"21","_key":"94b3f7b35c28"},{"text":" CFRs are local-level public health teams that include multidisciplinary membership (social services, law enforcement, health personnel, and medical examiners, among others). CFRs examine each unexpected child fatality in each jurisdiction, giving dignity to each child’s life and ensuring that prevention lessons might be learned when possible. New community support programs may be enacted. For example, American safe-haven laws, which allow parents to safely relinquish custody of unwanted unharmed infants, were borne out of CFRs.","_key":"0a062accfe4f","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"21","_key":"60e4457a96c1"},{"marks":[],"text":" There are additional initiatives put into place in medical settings to help prevent child maltreatment fatalities, including shaken baby prevention programs, no-hit zones and no-hit homes, sentinel injury detection training, and pediatric medical practice safety training modules and parent informational brochures, which help parents prepare to manage infant crying and toilet training safely.","_key":"1e7c55317a9f","_type":"span"},{"_key":"750a1bb8b2be","_type":"span","marks":["superscript"],"text":"10,22"}],"_type":"block","style":"normal","_key":"8bfca9e613fb","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"","_key":"42021edc567d0"}],"_type":"block","style":"normal","_key":"9c0bad14302c","markDefs":[]},{"style":"normal","_key":"86b716341a06","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Reporting","_key":"52dbd961162c0"}],"_type":"block"},{"markDefs":[],"children":[{"_key":"ea10c43cf6280","_type":"span","marks":[],"text":"Mental health professionals are required to report reasonable suspicions of child abuse and neglect to their local authorities."},{"_type":"span","marks":["superscript"],"text":"20","_key":"cda2acc77856"},{"_type":"span","marks":[],"text":" When making a report of suspected abuse and neglect, the medical professional should discuss they are making the report with the child’s family, starting with a neutral topic such as the patient’s status, and should do this in a private setting, maintaining their caring demeanor. Clinicians should ensure that the child’s family knows that medical professionals are required by law to make such reports but that their focus is on safety and they are not responsible for assessing blame. Clinicians can help prepare a family for the next steps, such as letting the family know to make themselves available to and cooperate with child welfare and law enforcement investigators. Lastly, one should reinforce that involved medical systems and providers should continue to have roles in the child’s ongoing physical and mental health and safety.","_key":"251ad6c0e275"}],"_type":"block","style":"normal","_key":"004b621f9c42"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bf12483c608d0"}],"_type":"block","style":"normal","_key":"6176ab7c3e4f"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"15adce0313a30"}],"_type":"block","style":"normal","_key":"c1d8c93f6a0b"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"In summary, understanding the potential motives for child murder by mothers can help in the prevention of child deaths, saving lives. In some but not all cases, mental illness is present in the mothers. Psychiatrists should be mindful of the risk and inquire about thoughts of suicide and filicide, keeping in mind the difference between ppOCD and postpartum psychosis. Psychiatrists have a valuable role in individual-level prevention as well as a potential public health role with CFRs.","_key":"e076d7685e4e0"}],"_type":"block","style":"normal","_key":"7ced584e4af1"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"f6275d6122250"}],"_type":"block","style":"normal","_key":"9af9e53103e0"},{"style":"normal","_key":"f67a1eb15738","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Hatters Friedman","_key":"ba4e1e33bb980"},{"_type":"span","marks":[],"text":" ","_key":"ba4e1e33bb981"},{"_type":"span","marks":["em"],"text":"is the Phillip J. Resnick Professor of Forensic Psychiatry; professor of psychiatry, reproductive biology, and pediatrics; and adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the Group for the Advancement of Psychiatry volume ","_key":"8c285e14610d"},{"_type":"span","marks":[],"text":"Family Murder: Pathologies of Love and Hate","_key":"1fb2461ee2ce"},{"_type":"span","marks":["em"],"text":", which won the Manfred S. Guttmacher Award.She is a pediatrician. ","_key":"07d5d9b1391f"},{"_key":"ba4e1e33bb984","_type":"span","marks":["strong"],"text":"Dr Friedman"},{"text":" is an assistant professor at Case Western Reserve University in Cleveland, Ohio.","_key":"ba4e1e33bb985","_type":"span","marks":[]}],"_type":"block"},{"_type":"block","style":"normal","_key":"0a8983b92b54","markDefs":[],"children":[{"marks":[],"text":"","_key":"ba06a399517b0","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"d6a27f7cdade0"}],"_type":"block","style":"normal","_key":"1ebd189487fa"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/5434623/","_key":"930a2b4fa7ae"}],"children":[{"_key":"531e9e4f32930","_type":"span","marks":[],"text":"1. Resnick PJ. "},{"_type":"span","marks":["930a2b4fa7ae"],"text":"Murder of the newborn: a psychiatric review of neonaticide.","_key":"531e9e4f32931"},{"_key":"b54c579d9f0e","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"Am J Psychiatry.","_key":"531e9e4f32932"},{"_type":"span","marks":[],"text":" 1970;126(10):1414-1420.","_key":"531e9e4f32933"}],"_type":"block","style":"normal","_key":"2e86e16c8a53"},{"markDefs":[],"children":[{"text":"2. Neonaticide. In: Friedman SH, ed. ","_key":"4037a6b2050b0","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"Family Murder: Pathologies of Love and Hate. ","_key":"4037a6b2050b1"},{"_type":"span","marks":[],"text":"American Psychiatric Association Press; 2018.","_key":"4037a6b2050b2"}],"_type":"block","style":"normal","_key":"78791e14f3e3"},{"children":[{"_type":"span","marks":[],"text":"3. Resnick PJ. ","_key":"04a1b8aa62890"},{"_type":"span","marks":["d2533a536bc0"],"text":"Child murder by parents: a psychiatric review of filicide.","_key":"04a1b8aa62891"},{"marks":[],"text":" ","_key":"2ebbecfecd4c","_type":"span"},{"_type":"span","marks":["em"],"text":"Am J Psychiatry.","_key":"04a1b8aa62892"},{"text":" 1969;126(3):325-334.","_key":"04a1b8aa62893","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"31c06acf0705","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/5801251/","_key":"d2533a536bc0"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/16394226/","_key":"8067e40d161c"}],"children":[{"marks":[],"text":"4. Friedman SH, Hrouda DR, Holden CE, et al. ","_key":"6f1ef953d4f20","_type":"span"},{"_type":"span","marks":["8067e40d161c"],"text":"Filicide-suicide: common factors in parents who kill their children and themselves.","_key":"6f1ef953d4f21"},{"marks":[],"text":" ","_key":"8075c559e17c","_type":"span"},{"_type":"span","marks":["em"],"text":"J Am Acad Psychiatry Law","_key":"6f1ef953d4f22"},{"_type":"span","marks":[],"text":". 2005;33(4):496-504.","_key":"6f1ef953d4f23"}],"_type":"block","style":"normal","_key":"61b98423a11a"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/16382847/","_key":"f520a71e2021"}],"children":[{"_key":"7bf1e9936ddd0","_type":"span","marks":[],"text":"5. Friedman SH, Hrouda DR, Holden CE, et al. "},{"_type":"span","marks":["f520a71e2021"],"text":"Child murder committed by severely mentally ill mothers: an examination of mothers found not guilty by reason of insanity.","_key":"7bf1e9936ddd1"},{"_type":"span","marks":[],"text":" ","_key":"2e3282a7e3af"},{"_type":"span","marks":["em"],"text":"J Forensic Sci","_key":"7bf1e9936ddd2"},{"text":". 2005;50(6):1466-1471.","_key":"7bf1e9936ddd3","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"cf34d4596bb2"},{"children":[{"text":"6. Friedman SH, Resnick PJ. ","_key":"2c9cc8d6d3a70","_type":"span","marks":[]},{"_type":"span","marks":["e1cfc5868579"],"text":"Child murder by mothers: patterns and prevention.","_key":"2c9cc8d6d3a71"},{"_type":"span","marks":[],"text":" ","_key":"452f50842263"},{"text":"World Psychiatry","_key":"2c9cc8d6d3a72","_type":"span","marks":["em"]},{"_key":"2c9cc8d6d3a73","_type":"span","marks":[],"text":". 2007;6(3):137-141."}],"_type":"block","style":"normal","_key":"37ad9cc00904","markDefs":[{"blank":true,"_type":"link","href":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174580/","_key":"e1cfc5868579"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.mdedge.com/psychiatry/article/263192/pediatrics/child-murder-parents-toward-prevention","_key":"c2635cb1e43d"}],"children":[{"text":"7. Friedman SH. ","_key":"2590ca266a3a0","_type":"span","marks":[]},{"_type":"span","marks":["c2635cb1e43d"],"text":"Child murder by parents: toward prevention.","_key":"2590ca266a3a1"},{"_type":"span","marks":[],"text":" ","_key":"a3443ec548a4"},{"_type":"span","marks":["em"],"text":"Current Psychiatry","_key":"2590ca266a3a2"},{"_key":"2590ca266a3a3","_type":"span","marks":[],"text":". 2023;22(6):12-21."}],"_type":"block","style":"normal","_key":"70f75e95b6d5"},{"style":"normal","_key":"2dd791db80e4","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/24094272/","_key":"ffd76e28e271"},{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/21680641/","_key":"637ac94b195d"}],"children":[{"_key":"4faa0d3a0c060","_type":"span","marks":[],"text":"8. Palusci VJ, Covington TM. "},{"_key":"4faa0d3a0c061","_type":"span","marks":["ffd76e28e271"],"text":"Child maltreatment deaths in the US National Child Death Review Case Reporting System."},{"_type":"span","marks":[],"text":" ","_key":"6f12966da411"},{"text":"Child Abuse Negl.","_key":"4faa0d3a0c062","_type":"span","marks":["em"]},{"marks":[],"text":" 2014;38(1):25-36.\n9. Putnam-Hornstein E. ","_key":"4faa0d3a0c063","_type":"span"},{"marks":["637ac94b195d"],"text":"Report of maltreatment as a risk factor for injury death: a prospective birth cohort study.","_key":"4faa0d3a0c064","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"d7ab7bb25f9c"},{"_key":"4faa0d3a0c065","_type":"span","marks":["em"],"text":"Child Maltreat"},{"_type":"span","marks":[],"text":". 2011;16(3):163-174.","_key":"4faa0d3a0c066"}],"_type":"block"},{"markDefs":[{"_key":"61610c589017","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/23478861/"}],"children":[{"_type":"span","marks":[],"text":"10. Sheets LK, Leach ME, Koszewski IJ, et al. ","_key":"10e8735666300"},{"_key":"10e8735666301","_type":"span","marks":["61610c589017"],"text":"Sentinel injuries in infants evaluated for child physical abuse."},{"_type":"span","marks":[],"text":" ","_key":"11a5c7f72c78"},{"marks":["em"],"text":"Pediatrics","_key":"10e8735666302","_type":"span"},{"_key":"10e8735666303","_type":"span","marks":[],"text":". 2013;131(4):701-707."}],"_type":"block","style":"normal","_key":"73c0dd33d3f4"},{"_type":"block","style":"normal","_key":"fe63a2807167","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/24618521/","_key":"5c14bdd557c1","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"11. Booth BD, Friedman SH, Curry S, et al. ","_key":"7c9e62c0c89d0"},{"_type":"span","marks":["5c14bdd557c1"],"text":"Obsessions of child murder: underrecognized manifestations of obsessive-compulsive disorder.","_key":"7c9e62c0c89d1"},{"_key":"e03eddb747df","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"J Am Acad Psychiatry Law","_key":"7c9e62c0c89d2"},{"marks":[],"text":". 2014;42(1):66-74.","_key":"7c9e62c0c89d3","_type":"span"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18463941/","_key":"cad91150e79e"}],"children":[{"_key":"8570968653810","_type":"span","marks":[],"text":"12. Fairbrother N, Woody SR. "},{"_type":"span","marks":["cad91150e79e"],"text":"New mothers’ thoughts of harm related to the newborn.","_key":"8570968653811"},{"marks":[],"text":" ","_key":"5bbe8e621ca6","_type":"span"},{"_type":"span","marks":["em"],"text":"Arch Womens Ment Health","_key":"8570968653812"},{"_type":"span","marks":[],"text":". 2008;11(3):221-229.","_key":"8570968653813"}],"_type":"block","style":"normal","_key":"ea07cca5806d"},{"_key":"6d0bf9b1efdc","markDefs":[{"blank":true,"_type":"link","href":"https://www.mdedge.com/psychiatry/article/197703/schizophrenia-other-psychotic-disorders/postpartum-psychosis-protecting","_key":"00017a7ff9f3"}],"children":[{"_type":"span","marks":[],"text":"13. Friedman SH, Prakash C, Nagle-Yang S. ","_key":"1499e0fd4fbf0"},{"text":"Postpartum psychosis: protecting mother and infant.","_key":"1499e0fd4fbf1","_type":"span","marks":["00017a7ff9f3"]},{"_type":"span","marks":[],"text":" ","_key":"696b02b2a1c3"},{"_type":"span","marks":["em"],"text":"Current Psychiatry","_key":"1499e0fd4fbf2"},{"marks":[],"text":". 2019;18(4):12-21.","_key":"1499e0fd4fbf3","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/16937315/","_key":"1a14ff85ed0f","blank":true}],"children":[{"_key":"21b050ad71bf0","_type":"span","marks":[],"text":"14. Chandra PS, Bhargavaraman RP, Raghunandan VNGP, Shaligram D. "},{"_type":"span","marks":["1a14ff85ed0f"],"text":"Delusions related to infant and their association with mother–infant interactions in postpartum psychotic disorders.","_key":"21b050ad71bf1"},{"_type":"span","marks":[],"text":" ","_key":"52a3d75114b4"},{"text":"Arch Womens Ment Health","_key":"21b050ad71bf2","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2006;9(5):285-288.","_key":"21b050ad71bf3"}],"_type":"block","style":"normal","_key":"7866e3bc6fae"},{"markDefs":[{"_key":"6758e5560759","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/29089007/"}],"children":[{"_type":"span","marks":[],"text":"15. Friedman SH, McEwan MV. ","_key":"fc3928df87890"},{"marks":["6758e5560759"],"text":"Treated mental illness and the risk of child abuse perpetration.","_key":"fc3928df87891","_type":"span"},{"_key":"4a3c9ee003b1","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"Psychiatr Serv","_key":"fc3928df87892"},{"_type":"span","marks":[],"text":". 2018;69(2):211-216.","_key":"fc3928df87893"}],"_type":"block","style":"normal","_key":"f07dbe99e512"},{"markDefs":[{"_key":"4fc509efdf46","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27836161/"}],"children":[{"_key":"4a43031e92a60","_type":"span","marks":[],"text":"16. McEwan M, Friedman SH. "},{"_type":"span","marks":["4fc509efdf46"],"text":"Violence by parents against their children: reporting of maltreatment suspicions, child protection, and risk in mental illness.","_key":"4a43031e92a61"},{"text":" ","_key":"0565fb01d715","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"Psychiatr Clin North Am","_key":"4a43031e92a62"},{"_type":"span","marks":[],"text":". 2016;39(4):691-700.","_key":"4a43031e92a63"}],"_type":"block","style":"normal","_key":"114d038164e9"},{"_key":"434a367f0f3a","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18063049/","_key":"1e168b4be470"}],"children":[{"marks":[],"text":"17. Friedman SH, Sorrentino RM, Stankowski JE, et al. ","_key":"400bf45969c60","_type":"span"},{"marks":["1e168b4be470"],"text":"Psychiatrists’ knowledge about maternal filicidal thoughts.","_key":"400bf45969c61","_type":"span"},{"_key":"2b9c0f4cd159","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"Compr Psychiatry","_key":"400bf45969c62"},{"_type":"span","marks":[],"text":". 2008;49(1):106-110. ","_key":"400bf45969c63"}],"_type":"block","style":"normal"},{"_key":"d69273910df0","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/19074717/","_key":"8cf2a8635fc3"}],"children":[{"_type":"span","marks":[],"text":"18. Barr JA, Beck CT. 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\"cariprazine\", \"iloperidone\", \"Quetiapine\", \"lithium\", \"venlafaxine\", \"desvenlafaxine\", \"escitalopram\", \"metformin\"]}","title":"Coping with Diagnostic Uncertainty in Mixed States: Comparing Treatment Risks","summary":"Let’s compare treatment risks when managing mixed states. ","contentCategory":{"_createdAt":"2020-02-06T09:15:47Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","_updatedAt":"2020-02-25T09:35:56Z"},"articleType":"News","thumbnail":{"_type":"mainImage","alt":"bipolar","caption":"matiasdelcarmine/AdobeStock","asset":{"_ref":"image-7466224b747025da7c84318fef9678a0f34e2c49-3673x2960-jpg","_type":"reference"}},"taxonomyMapping":[{"cmeType":"per","_rev":"77mZ7PORfofI3dBGfWalU3","_updatedAt":"2023-03-31T19:08:00Z","parent":{"_rev":"uvXJooXtzvjNOyx50HTt8m","_type":"taxonomy","name":"Topics","_id":"pst_taxonomy_53202_clinical","_updatedAt":"2023-03-31T19:15:59Z","parent":null,"isMainTopic":true,"_createdAt":"2020-03-26T06:11:21Z","identifier":"topics"},"_type":"taxonomy","name":"Bipolar Disorder","identifier":"topics/bipolar","perKeywordMapping":["Psychiatry","Neurology"],"_id":"pst_taxonomy_52_bipolardisorder","_createdAt":"2020-03-26T06:11:21Z","pixelTrackingCode":null},{"pixelTrackingCode":null,"parent":{"_createdAt":"2020-03-26T06:11:21Z","_rev":"uvXJooXtzvjNOyx50HTt8m","parent":null,"_id":"pst_taxonomy_53202_clinical","_updatedAt":"2023-03-31T19:15:59Z","identifier":"topics","isMainTopic":true,"name":"Topics","_type":"taxonomy"},"cmeType":"per","_type":"taxonomy","_updatedAt":"2024-02-29T16:00:14Z","name":"Major Depressive Disorder","perKeywordMapping":["Psychiatry","Neurology"],"_id":"pst_taxonomy_238_majordepressivedisorder","identifier":"topics/major-depressive-disorder","_createdAt":"2020-03-26T06:11:21Z","_rev":"r4Rkjy04WvWq5fuPdnwLCI"},{"_id":"pst_taxonomy_339_ptsd","_rev":"IakUcQKwj7kr3xQjaaTSXO","_type":"taxonomy","_createdAt":"2020-03-26T06:11:21Z","name":"PTSD","pixelTrackingCode":null,"_updatedAt":"2024-02-21T20:35:27Z","identifier":"topics/ptsd","parent":{"_type":"taxonomy","_updatedAt":"2023-03-31T19:15:59Z","identifier":"topics","parent":null,"isMainTopic":true,"_createdAt":"2020-03-26T06:11:21Z","_rev":"uvXJooXtzvjNOyx50HTt8m","name":"Topics","_id":"pst_taxonomy_53202_clinical"}},{"_createdAt":"2020-03-26T06:11:21Z","_type":"taxonomy","name":"Depression","perKeywordMapping":["Psychiatry","Neurology"],"pixelTrackingCode":null,"_rev":"eEqAv6Sbdk37RM523WcvVR","_id":"pst_taxonomy_641_depression","cmeType":"per","parent":null,"_updatedAt":"2024-02-28T20:45:13Z","identifier":"topics/depression"}],"published":"2024-11-26T16:00:00.000Z","audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/d6ba6b71-6f80-43bf-8395-883a2728f7bb_1731357840116.d3bbde24-0373-4319-9cbb-92d3c5c1db5e.mp3","_updatedAt":"2024-11-21T16:16:56Z","_createdAt":"2024-11-11T20:43:59Z","is_visible":true,"gptSummary":"Marissa's case highlights the diagnostic challenges in distinguishing between mixed depression and depression with PTSD. Her history suggests potential bipolarity, complicating treatment decisions. Antidepressants and lamotrigine are considered, with the latter offering better tolerability but less obvious applicability without hypomania history. The risks of antidepressant withdrawal and lamotrigine allergy, particularly Stevens-Johnson Syndrome, are compared. The article emphasizes the importance of patient education and weighing treatment risks, especially when diagnosis is uncertain. Clinicians should remain open to alternative explanations until effective outcomes are achieved.","_rev":"CD9JqQ0bQG227zfp2Rriu3","_id":"d6ba6b71-6f80-43bf-8395-883a2728f7bb","authorMapping":[{"_type":"author","_id":"pst_author_323669","_updatedAt":"2020-08-21T07:23:47Z","url":{"current":"james-phelps-md","_type":"slug"},"displayName":"James Phelps, MD","_createdAt":"2020-02-21T11:23:21Z","_rev":"pI9SawGKsTP14Lioy52fLS"}],"_type":"article","gptTakeaways":"• Marissa's symptoms suggest mixed depression or depression with PTSD, complicating diagnosis and treatment decisions.\n\n• Antidepressants and lamotrigine are considered, with lamotrigine offering better tolerability but less obvious applicability.\n\n• Antidepressant withdrawal and lamotrigine allergy risks are compared, influencing treatment choice.\n\n• Patient education and weighing treatment risks are crucial when diagnosis is uncertain.","authors":[{"displayName":"James Phelps, MD","url":"james-phelps-md"}],"documentGroupMapping":null,"body":[{"alt":"bipolar","imgcaption":[{"children":[{"text":"matiasdelcarmine/AdobeStock","_key":"5027ca70270e0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"6cb0638d0561","markDefs":[]}],"_key":"106a481d4f62","alignment":"left","widthP":48,"disableTextWrap":false,"_type":"figure","asset":{"_ref":"image-7466224b747025da7c84318fef9678a0f34e2c49-3673x2960-jpg","_type":"reference"},"disableLightBox":true},{"markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/major-depressive-disorder","_key":"edf0ac03a5bc"},{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/sleep-disorders","_key":"4965cd747f01"}],"children":[{"_type":"span","marks":[],"text":"“Marissa” has a history of trauma and ","_key":"7e795a6e1eae0"},{"marks":["edf0ac03a5bc"],"text":"major depressive disorder","_key":"5427360ce6b1","_type":"span"},{"text":" (MDD). She reports feeling anxious and struggling with ","_key":"4f0759149411","_type":"span","marks":[]},{"_type":"span","marks":["4965cd747f01"],"text":"insomnia","_key":"b95fad16d960"},{"_type":"span","marks":[],"text":". Her partner gently notes that Marissa can be pretty angry sometimes. Marissa could have comorbid MDD and posttraumatic stress disorder (PTSD), or she could have a depressive mixed state (and perhaps PTSD as well). As described in the first essay in this 3-part series, Marissa’s symptoms alone will not differentiate these diagnoses. The last of 4 ways of coping with this diagnostic uncertainty discussed in Part 2, comparing the risks of treatment options, is presented here through Marissa’s case.","_key":"6533e3775a3b"}],"_type":"block","style":"normal","_key":"a22f563e8565"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"1ba3bee70f700","_type":"span"}],"_type":"block","style":"normal","_key":"0fba996494ae"},{"children":[{"_type":"span","marks":[],"text":"The ","_key":"ecb9243cb3330"},{"_type":"span","marks":["strong","f19d03b3a1df"],"text":"Figure","_key":"ecb9243cb3331"},{"_key":"ecb9243cb3332","_type":"span","marks":[],"text":" presents the spectrum of mixed states,"},{"marks":["superscript"],"text":"1","_key":"5d4ecb3a1e11","_type":"span"},{"_type":"span","marks":[],"text":" the diagnostic dilemma, and a way of thinking about treatment options.","_key":"bd12760aed44"}],"_type":"block","style":"normal","_key":"ad2f46951b26","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6516fcf6196099be52f4e555fd8cdbe9b9e604b8-1430x424.jpg%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"f19d03b3a1df"}]},{"disableTextWrap":false,"_type":"figure","alt":"Figure. The Spectrum of Mixed States","_key":"2ca7a4d73fcb","asset":{"_ref":"image-6516fcf6196099be52f4e555fd8cdbe9b9e604b8-1430x424-jpg","_type":"reference"},"imgcaption":[{"_type":"block","style":"normal","_key":"24f40f8d3240","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure. ","_key":"2a364c834dd20"},{"_type":"span","marks":[],"text":"The Spectrum of Mixed States","_key":"cdb60e349dd9"}]}],"alignment":"right","widthP":60,"blank":true,"disableLightBox":true},{"children":[{"text":"","_key":"92aacbdd3c6c0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b2deed03ef4f","markDefs":[]},{"markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/ptsd","_key":"c72c831c2bda"}],"children":[{"_type":"span","marks":[],"text":"Suppose Marissa, who is 28 years old, has a cousin with possible bipolar disorder, had her first episode of depression at age 20 and 2 episodes since, one of which occurred shortly after the birth of her 2-year-old daughter. Sertraline made her insomnia much worse, so she stopped it. These features raise the probability of bipolarity, but only weakly vs (for example) a strong family history, earlier age of onset, more frequent episodes, and a more adverse response to sertraline. The diagnostic question remains: mixed depression or depression with ","_key":"36e5351be6e30"},{"_type":"span","marks":["c72c831c2bda"],"text":"PTSD","_key":"9cbd42080cbf"},{"_type":"span","marks":[],"text":"?","_key":"f83d429f5c34"}],"_type":"block","style":"normal","_key":"29f6fcdbaca3"},{"_type":"block","style":"normal","_key":"fca1ef6e806c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"011ba4469c3e0"}]},{"_key":"c723e6fccf17","markDefs":[],"children":[{"text":"After patient education (discussed in Part 2), Marissa understands this differential and prefers a medication approach over psychotherapy (even after digital options are presented). A direct comparison of treatment approaches is warranted.","_key":"2fbdbd75a7e00","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"fa84f41ebd4c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"87cf5f9f67cc0"}]},{"children":[{"_type":"span","marks":["strong"],"text":"Antidepressants or Lamotrigine?","_key":"ad5e1574e2b70"}],"_type":"block","style":"normal","_key":"2a939ed1a45e","markDefs":[]},{"_type":"block","style":"normal","_key":"03e8bc05f80e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Antidepressants are an obvious option for Marissa. They have modest benefits in both depression","_key":"543efd4c87450"},{"_type":"span","marks":["superscript"],"text":"2","_key":"2be77bca8ff7"},{"_type":"span","marks":[],"text":" and PTSD.","_key":"6cc301ed211a"},{"_type":"span","marks":["superscript"],"text":"3","_key":"bde495c2ec7a"},{"marks":[],"text":" Lamotrigine is not so obvious. Here’s the logic.","_key":"7bdfbeb80edf","_type":"span"}]},{"style":"normal","_key":"43af0cf913eb","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7bda3815a6030"}],"_type":"block"},{"_type":"block","style":"normal","_key":"1f193cab6eb9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Treatment guidelines for mixed states","_key":"806dbdc007950"},{"_type":"span","marks":["strikethrough"],"text":"4","_key":"f4fdb1e69bbd"},{"marks":[],"text":" are based primarily on efficacy in short-term RCTs funded by pharmaceutical companies in their pursuit of US Food and Drug Administration approval. Older medications are less studied. No randomized trials have been conducted for broadly defined mixed states (see Part 1).","_key":"cb53f95426f8","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"dbf1d41106e50"}],"_type":"block","style":"normal","_key":"b73e150b5645"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Tolerability (adverse effects and long-term risks) frequently determines patients’ choice, rather than highest efficacy, particularly if symptoms are chronic not acute. Lamotrigine has the best tolerability amongst the mood stabilizers with antidepressant effects. (Lurasidone lacks decades of use to fully understand its long-term risks; likewise for lumateperone, cariprazine, and iloperidone. Quetiapine can cause insulin resistance, which appears to contribute to treatment resistance.","_key":"b13a437632a10"},{"_type":"span","marks":["superscript"],"text":"5","_key":"019ccde9bdcb"},{"text":" Even low doses of lithium can cause hypothyroidism.","_key":"2edc7e75dde3","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"6","_key":"8742b382f81a"},{"marks":[],"text":")","_key":"6a4399bcb80a","_type":"span"}],"_type":"block","style":"normal","_key":"03b178c94582"},{"_type":"block","style":"normal","_key":"c69636a57931","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"fc5c7007498e0"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Extrapolating Treatment Options","_key":"8e91f866e7cc0"}],"_type":"block","style":"normal","_key":"cd783dba1c29"},{"style":"normal","_key":"cc6a6ebd7b49","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6516fcf6196099be52f4e555fd8cdbe9b9e604b8-1430x424.jpg%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"b08e775e8ebd","nofollow":true,"blank":true}],"children":[{"text":"As shown in the ","_key":"6aa1edca5d450","_type":"span","marks":[]},{"_type":"span","marks":["strong","b08e775e8ebd"],"text":"Figure","_key":"6aa1edca5d451"},{"_key":"6aa1edca5d452","_type":"span","marks":[],"text":", by extrapolating from experience in MDD, antidepressants can be considered for mixed depressions. Likewise, by extrapolating from experience in bipolar II, lamotrigine can also be considered."}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"","_key":"5deb7c538fed0"}],"_type":"block","style":"normal","_key":"66ef1f58aae4","markDefs":[]},{"style":"normal","_key":"d5b7da354092","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Many practitioners are hesitant to consider lamotrigine unless a history of hypomania or mania is obtained. Indeed, while it makes sense to consider antidepressants for depression comorbid with PTSD or generalized anxiety disorder; there is no obvious reason to consider lamotrigine for these conditions—","_key":"476898db106a0"},{"_type":"span","marks":["em"],"text":"except when a depressive mixed state is","_key":"476898db106a1"},{"_type":"span","marks":[],"text":" ","_key":"476898db106a2"},{"_type":"span","marks":["em"],"text":"equally likely the correct diagnosis","_key":"476898db106a3"},{"marks":[],"text":".","_key":"476898db106a4","_type":"span"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"Marissa has surely heard of antidepressants. The patient education discussed in Part 2 will help her understand why lamotrigine is also an option. Now, compare their risks.","_key":"91f1e5526fb70"}],"_type":"block","style":"normal","_key":"0c404d5d9731","markDefs":[]},{"_key":"d83c9a09f76f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"1e114e8abd5a0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"1393f71c02e9","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Comparing Major Risks","_key":"05edbe0d4a570"}],"_type":"block"},{"_type":"block","style":"normal","_key":"f4ef953c49dd","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The efficacy of antidepressants vs lamotrigine in broadly defined mixed states has not been studied. But two tolerability concerns are well known: antidepressant withdrawal and lamotrigine allergy. Understanding these risks may have a strong impact on treatment choice when diagnosis is uncertain.","_key":"44a536ceab3e0"}]},{"style":"normal","_key":"5b2d958b5eda","markDefs":[],"children":[{"text":"","_key":"90419e037c460","_type":"span","marks":[]}],"_type":"block"},{"_type":"block","style":"normal","_key":"20ffdaacc454","markDefs":[],"children":[{"marks":[],"text":"Patients often weigh these risks very differently. For some, hearing the risk of Stevens-Johnson Syndrome (SJS) precludes any further consideration, regardless of how one explains its incidence. For others who may have known someone who struggled to discontinue their antidepressant, concerns about withdrawal might strongly affect their treatment choice.","_key":"d125a9d56d260","_type":"span"}]},{"_type":"block","style":"normal","_key":"b5ad5791878c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"61369c75509e0"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Incidence of Severe Antidepressant Withdrawal","_key":"db6bafd86f7c0"}],"_type":"block","style":"normal","_key":"af347c3875db"},{"style":"normal","_key":"4e99b7b89be1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Different sources estimate very different rates of severe withdrawal. In one podcast interview, academic psychiatrist Michael Thase suggested an incidence of 1% to 2%.","_key":"da877787f1940"},{"text":"7","_key":"3772e72c011d","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Other authors, including those of a review of data published through 2022,","_key":"48aad7c98ca9"},{"text":"8","_key":"8791886a2187","_type":"span","marks":["superscript"]},{"text":" believe the rate is much higher, at least 10% (Mark Horowitz, personal communication). That review notes important effects of dose, duration of treatment, and differences between antidepressants. Obviously, the definition of “severe” also affects rates.","_key":"f41020550da7","_type":"span","marks":[]}],"_type":"block"},{"children":[{"text":"","_key":"7e8abe0f298e0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"36bf88991a3c","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"A 2024 review of 79 studies found a 3% rate of severe withdrawal (higher for venlafaxine, desvenlafaxine and escitalopram).","_key":"be355eecfa340"},{"text":"9","_key":"57374b827bec","_type":"span","marks":["superscript"]},{"_key":"cbd52f6a3b5b","_type":"span","marks":[],"text":" Lastly, a post-hoc analysis of a recent randomized trial of antidepressant discontinuation found a rate of significant withdrawal of 16% (4 or more emergent symptoms, but not necessarily “severe”; see Response to a Comment by Horowitz)."},{"_type":"span","marks":["superscript"],"text":"10","_key":"6e6dace49d60"}],"_type":"block","style":"normal","_key":"1ffc088e8e34"},{"_key":"096653bbb12c","markDefs":[],"children":[{"marks":[],"text":"","_key":"1f972ea23ec60","_type":"span"}],"_type":"block","style":"normal"},{"style":"normal","_key":"6a044b590b38","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Withdrawal vs Stevens-Johnson Syndrome","_key":"1520ab2300ba0"}],"_type":"block"},{"_key":"f3e70f58d6b1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Comparing antidepressant withdrawal and extreme allergic reactions to lamotrigine is obviously like comparing apples and oranges. Nevertheless, for a very rough impression of relative risk, comparing their rates may be useful. 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Using these figures, severe withdrawal is 100 times more common than SJS and 500 times the SJS death rate. Severe withdrawal has been associated with suicidal ideation, but not death by suicide.","_key":"d84da16105020"},{"_type":"span","marks":["superscript"],"text":"13","_key":"54b2dde04a8f"},{"text":" On the other hand, very severe withdrawal can be life-limiting for months to years, as attested by thousands of online accounts.","_key":"b22c4b2610a0","_type":"span","marks":[]},{"marks":["superscript"],"text":"14","_key":"0792677bf0d5","_type":"span"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"d1245bfe2e6e0"}],"_type":"block","style":"normal","_key":"24d667ac5bc6","markDefs":[]},{"_key":"27dcfd896a12","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Marissa has yet to make her decision between these 2 options. 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Stahl SM, Morrissette DA, Faedda G, et al. ","_key":"08c068792bd00"},{"_type":"span","marks":["9b26d8748925"],"text":"Guidelines for the recognition and management of mixed depression.","_key":"08c068792bd01"},{"_type":"span","marks":[],"text":" ","_key":"f302efca0013"},{"marks":["em"],"text":"CNS Spectr","_key":"08c068792bd02","_type":"span"},{"_type":"span","marks":[],"text":". 2017;22(2):203-219.","_key":"08c068792bd03"}],"_type":"block","style":"normal","_key":"dceb60e768b1"},{"markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/29477251/","_key":"408441d8ddfb","blank":true}],"children":[{"_type":"span","marks":[],"text":"2. Cipriani A, Furukawa TA, Salanti G, et al. ","_key":"00fa1fc2fc320"},{"marks":["408441d8ddfb"],"text":"Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.","_key":"00fa1fc2fc321","_type":"span"},{"_key":"a20a729eaf83","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"Lancet","_key":"00fa1fc2fc322"},{"_type":"span","marks":[],"text":". 2018;391(10128):1357-1366.","_key":"00fa1fc2fc323"}],"_type":"block","style":"normal","_key":"b1a15ee73baf"},{"_key":"995a0c827b5e","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/38869978/","_key":"643d4d15c6c8"}],"children":[{"text":"3. Guidetti C, Feeney A, Hock RS, et al. ","_key":"e0fa411b9d820","_type":"span","marks":[]},{"_type":"span","marks":["643d4d15c6c8"],"text":"Antidepressants in the acute treatment of post-traumatic stress disorder in adults: a systematic review and meta-analysis.","_key":"e0fa411b9d821"},{"_key":"f17e3a426898","_type":"span","marks":[],"text":" "},{"_key":"e0fa411b9d822","_type":"span","marks":["em"],"text":"Int Clin Psychopharmacol"},{"_key":"e0fa411b9d823","_type":"span","marks":[],"text":". 2024."}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/35053835/","_key":"8c739eb8922f"}],"children":[{"_type":"span","marks":[],"text":"4. Natale A, Mineo L, Fusar-Poli L, et al. 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"},{"_type":"span","marks":["ad9727862d87"],"text":"Treating insulin resistance with metformin as a strategy to improve clinical outcomes in treatment-resistant bipolar depression (the TRIO-BD Study): a randomized, quadruple-masked, placebo-controlled clinical trial.","_key":"39a3f4bdecae1"},{"_type":"span","marks":[],"text":" ","_key":"f8d36a48ed08"},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry","_key":"39a3f4bdecae2"},{"text":". 2022;83(2):21m14022.","_key":"39a3f4bdecae3","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"1a16d566767d","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/35120288/","_key":"ad9727862d87"}]},{"children":[{"_type":"span","marks":[],"text":"6. Phelps J, Coskey OP. ","_key":"d5b024649e080"},{"marks":["5982e74453aa"],"text":"Low and very low lithium levels: thyroid effects are small but still require monitoring.","_key":"d5b024649e081","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"ccf7ce065454"},{"_type":"span","marks":["em"],"text":"Bipolar Disord","_key":"d5b024649e082"},{"_key":"d5b024649e083","_type":"span","marks":[],"text":". 2024;26(2):129-135."}],"_type":"block","style":"normal","_key":"e978bf17a068","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/37704933/","_key":"5982e74453aa"}]},{"_type":"block","style":"normal","_key":"87080d705305","markDefs":[],"children":[{"marks":[],"text":"7. Thase M. Webinar, Psychopharmacology Institute. Response to Listener Question. 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","_key":"99f12ec223830"},{"marks":["1de45711ba0a"],"text":"Internet and telephone support for discontinuing long-term antidepressants: the REDUCE cluster randomized trial.","_key":"99f12ec223831","_type":"span"},{"text":" ","_key":"91599962f418","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"JAMA Netw Open.","_key":"99f12ec223832"},{"_type":"span","marks":[],"text":" 2024;7(6):e2418383.","_key":"99f12ec223833"}],"_type":"block","style":"normal","_key":"2009c0d00aac"},{"_type":"block","style":"normal","_key":"3e8601caaa40","markDefs":[{"_key":"bdb6bb48ad81","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/28225977/"}],"children":[{"_type":"span","marks":[],"text":"11. Bloom R, Amber KT. ","_key":"b1309b9e34740"},{"_type":"span","marks":["bdb6bb48ad81"],"text":"Identifying the incidence of rash, Stevens-Johnson syndrome and toxic epidermal necrolysis in patients taking lamotrigine: a systematic review of 122 randomized controlled trials.","_key":"b1309b9e34741"},{"text":" ","_key":"21cbca0aca7a","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"An Bras Dermatol. ","_key":"b1309b9e34742"},{"text":"2017;92(1):139-141.","_key":"b1309b9e34743","_type":"span","marks":[]}]},{"children":[{"_type":"span","marks":[],"text":"12. Hsu DY, Brieva J, Silverberg NB, Silverberg JI. ","_key":"bae383e28fa70"},{"_type":"span","marks":["10b35fc637fd"],"text":"Morbidity and mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis in United States adults.","_key":"bae383e28fa71"},{"_type":"span","marks":[],"text":" ","_key":"e8fdcc158bad"},{"_key":"bae383e28fa72","_type":"span","marks":["em"],"text":"J Invest Dermatol"},{"_type":"span","marks":[],"text":". 2016;136(7):1387-1397.","_key":"bae383e28fa73"}],"_type":"block","style":"normal","_key":"e7f5a966f0c9","markDefs":[{"_key":"10b35fc637fd","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/27039263/"}]},{"_type":"block","style":"normal","_key":"a2ac89e04cf8","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/38270549/","_key":"6e48007f1402"}],"children":[{"_type":"span","marks":[],"text":"13. Kostic M, Plöder M, Hengartner M, Buzejic J. ","_key":"0827733d682d0"},{"text":"Suicidality emerging from rapid venlafaxine discontinuation: a challenge–dechallenge–rechallenge case report.","_key":"0827733d682d1","_type":"span","marks":["6e48007f1402"]},{"_type":"span","marks":[],"text":" ","_key":"2f0083c0471c"},{"_type":"span","marks":["em"],"text":"J Clin Psychiatry","_key":"0827733d682d2"},{"text":". 2024;85(1):23cr14930.","_key":"0827733d682d3","_type":"span","marks":[]}]},{"markDefs":[{"_key":"7977f3f7de1d","blank":true,"_type":"link","href":"https://www.survivingantidepressants.org"}],"children":[{"_type":"span","marks":[],"text":"14. Surviving Antidepressants. Accessed November 7, 2024. 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The complexity of diagnosing malingering is compounded by the potential for stigma and misdiagnosis, necessitating comprehensive psychiatric assessments. Malingering can manifest as pure, partial, or false imputation, with psychosis being the most commonly feigned condition. The financial and systemic burdens of malingering are significant, impacting trial processes and healthcare costs. Ethical considerations and thorough evaluations are crucial in addressing malingering effectively.","ExcludeFromPubMedXML":false,"_updatedAt":"2024-11-21T16:02:57Z","drugMentions":"{\"drug_mentions\": []}","_type":"article","factCheckAuthorMapping":null,"documentGroup":null,"_rev":"LMsvoO9kT4cTyaW2IJui8f","contentCategory":{"_createdAt":"2020-02-06T09:15:47Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Articles","_id":"8bdaa7fc-960a-4b57-b076-75fdce3741bb","_updatedAt":"2020-02-25T09:35:56Z"},"summary":"Learn more about malingering in this forensic psychiatry overview. ","is_visible":true,"gptTakeaways":"• Malingering in forensic settings is driven by motives like avoiding incarceration and obtaining medications, necessitating careful psychiatric assessments to avoid misdiagnosis and stigma.\n\n• Malingering can be categorized into pure, partial, and false imputation, with psychosis being the most commonly feigned condition due to its overt nature.\n\n• The financial and systemic burdens of malingering are significant, affecting trial processes and healthcare costs, highlighting the need for thorough evaluations.\n\n• Ethical considerations in diagnosing malingering are crucial, requiring comprehensive assessments and adherence to forensic psychiatry guidelines to ensure justice and objectivity.","url":"malingering-in-the-forensic-and-correctional-settings","_createdAt":"2024-11-14T19:48:48Z","title":"Malingering in the Forensic and Correctional Settings","thumbnail":{"alt":"forensic psychiatry","caption":"rolffimages/AdobeStock","asset":{"_ref":"image-d83dbdbc3902e16c8b0970cd5584988f4f9c4852-3092x2019-jpg","_type":"reference"},"_type":"mainImage"},"published":"2024-11-21T16:00:00.000Z","audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/d7832425-aeca-42fe-be93-2b01217d8e08_1731614935022.2ec1727e-4466-425c-b55c-ad59dfafe9e5.mp3","articleType":"News","taxonomyMapping":[{"_rev":"uvXJooXtzvjNOyx50HTwBg","name":"Forensic Psychiatry","_id":"pst_taxonomy_173_forensicpsychiatry","identifier":"topics/forensic","perKeywordMapping":["Psychiatry","Neurology"],"cmeType":"per","pixelTrackingCode":null,"parent":{"_id":"pst_taxonomy_53202_clinical","_updatedAt":"2023-03-31T19:15:59Z","identifier":"topics","isMainTopic":true,"parent":null,"_createdAt":"2020-03-26T06:11:21Z","_type":"taxonomy","_rev":"uvXJooXtzvjNOyx50HTt8m","name":"Topics"},"_createdAt":"2020-03-26T06:11:21Z","_type":"taxonomy","_updatedAt":"2023-03-31T19:16:52Z"},{"name":"Special Reports","_updatedAt":"2020-03-26T06:11:21Z","identifier":"special-reports","pixelTrackingCode":null,"_rev":"IlP9l41tH9jB20SbSpsYNi","_type":"taxonomy","_id":"pst_taxonomy_385_specialreports","parent":null,"_createdAt":"2020-03-26T06:11:21Z"}],"documentGroupMapping":null,"authorMapping":[{"_createdAt":"2024-11-14T19:49:19Z","_type":"author","_id":"827796e8-2ad9-42b4-b015-ac60eb1d270b","_updatedAt":"2024-11-14T19:50:07Z","url":{"current":"vikram-kumar-md","_type":"slug"},"authorType":"author","displayName":"Vikram Kumar, MD","_rev":"19MLiwy94z3PqhCfQiTD4L","biography":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Kumar ","_key":"2c066121bd9f0"},{"_key":"2c066121bd9f1","_type":"span","marks":["em"],"text":"is an early career forensic psychiatrist. He is an attending physician at a State forensic facility for the New York Office of Mental Health."}],"_type":"block","style":"normal","_key":"66c5ffd42ffd"}]}],"body":[{"asset":{"_ref":"image-d83dbdbc3902e16c8b0970cd5584988f4f9c4852-3092x2019-jpg","_type":"reference"},"disableLightBox":true,"alignment":"left","widthP":50,"disableTextWrap":false,"alt":"forensic psychiatry","imgcaption":[{"_type":"block","style":"normal","_key":"88789e455911","markDefs":[],"children":[{"marks":[],"text":"rolffimages/AdobeStock","_key":"94ea4a7381a70","_type":"span"}]}],"_key":"347006c3dbb3","_type":"figure"},{"_key":"c19f670f9506","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"SPECIAL REPORT: FORENSIC PSYCHIATRY","_key":"d8719e416f260"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Malingering, also known as the intentional feigning of symptoms for a secondary gain, is an ever-present entity in the realm of forensic and correctional facilities. However, within the same spheres, it proves to be a double-edged sword. While these settings themselves prove to be fertile grounds for falsification of symptoms, cue secondary gain, falsely applying the diagnosis of malingering can invite its own set of consequences. It can also raise profound connotations as psychiatric diagnoses are often viewed as labels, and what could be more stigmatizing, more labeling, as calling someone with mental illness a malingerer? This is not to imply that this is common practice but serves to act as a cautionary note to the reader.","_key":"1ee9e3f4835c0"}],"_type":"block","style":"normal","_key":"14b6c6abcaae"},{"_type":"block","style":"normal","_key":"7b242fe440dc","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In forensic and correctional facilities, motives for malingering illness can occur as an adaptation to the environment. Motives to malinger illness may include transfer within or to a less restrictive facility, extending length of stay to avoid jail time, procuring medications to divert, and many more. In September 2023, the Department of Justice published a report that states the US prison population numbered around 1.2 million in 2022.","_key":"0d8016b117410"},{"_type":"span","marks":["superscript"],"text":"1","_key":"476cb576c3a4"},{"_type":"span","marks":[],"text":" By the end of 2023, this number stood at 1.8 million.","_key":"f065dd69a72d"},{"_type":"span","marks":["superscript"],"text":"2","_key":"d6a47278b6d7"},{"_type":"span","marks":[],"text":" Keeping in mind that the US has the largest prison population in the world, this number is likely to keep growing. The era of deinstitutionalization, which began 6 decades ago, led to a decline in long-term psychiatric hospitalizations, however, resulting in increasing rates of incarceration.","_key":"3bc27499ce95"},{"_key":"dd157e3a889c","_type":"span","marks":["superscript"],"text":"3"}]},{"_key":"7f420b67858a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Much has been written about the living conditions of individuals who are incarcerated and that of the facilities themselves. With the COVID-19 pandemic, the added burden on the system has increased exponentially.","_key":"fde13b1f0f690"},{"text":"4","_key":"ba143a7dbcd1","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Therefore, overcrowding; confinement for long periods of time in a high-stress environment; high levels of stress; ongoing communicable diseases; and undiagnosed, untreated mental illness can create the optimal setting for feigning symptoms to facilitate transfer to better conditions. However, the very same conditions can lead to and exacerbate mental illnesses. Hence, the vitality of a complete psychiatric assessment combined with the utilization of data from historical sources and staff observations cannot be overemphasized.","_key":"ce681b6ca85c"}],"_type":"block","style":"normal"},{"style":"normal","_key":"9a7218e7a783","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"6988b3f079420"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Categories of Malingering","_key":"9828ea3e25250"}],"_type":"block","style":"normal","_key":"6dd4b201a566","markDefs":[]},{"children":[{"_key":"3620c546b8130","_type":"span","marks":[],"text":"Based on the production of symptoms, malingering can be further categorized as pure malingering, partial malingering, and false imputation."},{"_type":"span","marks":["superscript"],"text":"5","_key":"d936eb4cca5c"},{"text":" Simply put, the conscious production of nonexistent symptoms is termed as ","_key":"b523b975d65e","_type":"span","marks":[]},{"_key":"3620c546b8131","_type":"span","marks":["em"],"text":"pure malingering"},{"marks":[],"text":". When there is voluntary embellishment of already present symptoms of a disorder, it is considered ","_key":"3620c546b8132","_type":"span"},{"_type":"span","marks":["em"],"text":"partial malingering","_key":"3620c546b8133"},{"_type":"span","marks":[],"text":". Consciously ascribing preexisting symptoms to a completely unrelated cause constitutes ","_key":"3620c546b8134"},{"_type":"span","marks":["em"],"text":"false imputation","_key":"3620c546b8135"},{"_key":"3620c546b8136","_type":"span","marks":[],"text":". Malingering can occur in individuals with or without preexisting mental illnesses. The "},{"_type":"span","marks":["strong"],"text":"Figure ","_key":"3620c546b8137"},{"_type":"span","marks":[],"text":"illustrates the categories of malingering.","_key":"3620c546b8138"}],"_type":"block","style":"normal","_key":"85fd07369e59","markDefs":[]},{"blank":true,"disableTextWrap":false,"asset":{"_ref":"image-733042258ffcf0d609c429ea644bdf5acb03033b-1632x652-png","_type":"reference"},"alignment":"right","_type":"figure","disableLightBox":true,"alt":"Figure. Categories of Malingering","widthP":50,"imgcaption":[{"_key":"bc23356e7fb0","markDefs":[],"children":[{"_key":"0098dff292cf0","_type":"span","marks":["strong"],"text":"Figure. "},{"marks":[],"text":"Categories of Malingering","_key":"03e181d268a0","_type":"span"}],"_type":"block","style":"normal"}],"_key":"e389ee9c4e3d"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4ff67c1788be0"}],"_type":"block","style":"normal","_key":"aed1a3d0ad61"},{"_key":"94ad2aa5c93e","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Parable of 2 Hats","_key":"f06e7a936b370"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"00799eb96d56","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Much has been conjectured and written about the ethical principles of forensic psychiatrists. In his 1982 address to the American Psychiatric Association (APA) and its subsequent iterations, Alan Stone, MD, called into question the veracity of psychiatric testimony and equated his own questioning the ethicality of forensic psychiatry as him “coming down from the ivory tower.”","_key":"f871b2cf73720"},{"marks":["superscript"],"text":"6","_key":"4296adafd165","_type":"span"},{"_type":"span","marks":[],"text":" Close to a decade later, Paul Appelbaum, MD, put forth the aphorism that the forensic psychiatrist’s central role lay in the advancement of justice, honesty, and objectivity.","_key":"e28cb96f2190"},{"_type":"span","marks":["superscript"],"text":"7","_key":"29965150fdc4"},{"_type":"span","marks":[],"text":" These are guidelines that are adhered to by the American Association of Psychiatry and Law (AAPL) and ingrained into every trainee in a forensic psychiatry fellowship.","_key":"918a22e92c43"},{"_type":"span","marks":["superscript"],"text":"8","_key":"f5ea180b03f4"},{"_type":"span","marks":[],"text":" More than any others, malingering is an area that blurs the line between the 2 hats.","_key":"a421163343e5"}]},{"_key":"d8f673629aeb","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Forensic psychiatrists are experts at juggling between the 2 roles, and this is imperative, especially when considering the diagnosis of malingering in a forensic or correctional setting. Being highly contingent upon the environment, malingering can also be seen as an adaptation to it. In the forensic setting, one of the main drives to malinger symptoms of illness is to avoid prison sentences, the length of which could often be long-term or even life.","_key":"80e65d1f4dbe0"},{"_type":"span","marks":["superscript"],"text":"9","_key":"79c057c5df36"},{"_type":"span","marks":[],"text":" A 2013 study by McDermott et al found that prevalence rates of malingering in forensic settings range between 8% and 21%.","_key":"fc1199084cac"},{"marks":["superscript"],"text":"10","_key":"da586f43bbdb","_type":"span"},{"marks":[],"text":" In the same study, about 18% of patients deemed incompetent to stand trial were found to be malingering, and nearly 65% of incarcerated individuals needing psychiatric interventions were found to be malingering as well. Therefore, it is a clear and ever-present entity in these settings. These rates have stayed consistent across the board.","_key":"2ac91afa59b3","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"","_key":"221c5b3eb7c40","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"88d1a66522fe"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Burden of Malingering","_key":"0c91b15692250"}],"_type":"block","style":"normal","_key":"bd85aac062c2"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"From a public health perspective, malingering can be a costly affair. In forensic settings, it can delay outcomes such as trial and sentencing and unwarranted spending towards housing and medications. Other factors to consider include transport of patients to and from courts, referrals to specialists, and specialized testing outside facilities for further diagnostic clarifications. Most state systems are already facing a backlog of individuals awaiting competency to stand trial evaluations and malingering symptoms delays this process further.","_key":"0294f39082f90"},{"_key":"6c0fb7ae5f65","_type":"span","marks":["superscript"],"text":"11"},{"_type":"span","marks":[],"text":" When individuals falsely impute symptoms to a cause other than their illness, this can result in treatment that would not only be unhelpful but invite unnecessary medication adverse effects.","_key":"9bc6dd370b6c"}],"_type":"block","style":"normal","_key":"68ff7f94094b"},{"markDefs":[],"children":[{"marks":[],"text":"Dissimulation, which involves minimizing symptoms of mental illness to portray good health, can lead to individuals not receiving much-needed treatment.","_key":"93068a73c21f0","_type":"span"},{"text":"12","_key":"7cd0aac9f829","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Although there are differences in lengths of stay, services offered, and the metrics considered for billing purposes, admission to psychiatric inpatient facilities in the community costs about $1000 per patient.","_key":"80d5abcbcf5d"},{"text":"13","_key":"b13986b4fa10","_type":"span","marks":["superscript"]},{"text":" A 2024 cost study of Texas state hospitals showed the daily cost of an operational bed to be $736.41 for civil and $744.96 for forensic hospitals.","_key":"d280609bfc24","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"14","_key":"4b4285f2abc1"},{"_type":"span","marks":[],"text":" Considering for example, an individual who is deemed incompetent to stand trial, admission to a forensic state facility may last anywhere from 90 days to a year or longer, depending on restorability. When these numbers are extrapolated together, the cost and expenditures are staggering.","_key":"92aa8e0ce82b"}],"_type":"block","style":"normal","_key":"fa4f4ed18258"},{"markDefs":[],"children":[{"_key":"141d6db7928a0","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"d986bdfcbc1a"},{"children":[{"_type":"span","marks":["strong"],"text":"Malingered Psychiatric Symptoms in Forensic and Correctional Settings","_key":"5475cae376f80"}],"_type":"block","style":"normal","_key":"42be35d4eec1","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Psychosis is often most malingered, due to its overt and reproducible nature. Incentives to malinger psychosis typically involve psychiatric hospitalization to avoid prison or jail time; however, it is usually dynamic and multifaceted. Within the sphere of psychosis, individuals are more likely to report visual hallucinations, followed by auditory hallucinations and delusions.","_key":"ce92d87ef4b80"},{"_type":"span","marks":["superscript"],"text":"12","_key":"86901f4e5168"},{"text":" It is imperative to consider and rule out pathologies such as substance use and organic conditions in which visual hallucinations are seen as well. Malingered psychotic symptoms are characteristically noted to be atypical, out of proportion with the overall severity of the individual’s illness, and with notable inconsistencies in self and staff reports.","_key":"e64971f0ddd7","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"320f6cb4316f"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"At the same time, it is important to keep in mind that atypical symptoms by themselves do not directly equate to malingering. As noted by McCarthy-Jones and Resnick, atypical auditory hallucinations ranged from being completely silent (reported by 5% of patients) to playing out like an idea inside their head (44% of patients) as opposed to coming from outside. In addition, the voices could also be heard as coming from different parts of the body.","_key":"a9d81aa2aa210"},{"marks":["superscript"],"text":"15","_key":"d7233d373266","_type":"span"},{"_type":"span","marks":[],"text":" This further emphasizes the need for contextual considerations and an extremely thorough evaluation using multiple sources of information. When individuals feign delusional content, the onset and abatement of symptoms are generally atypical compared with the norm.","_key":"c358f7386860"},{"_type":"span","marks":["superscript"],"text":"12","_key":"0ca77017c981"},{"_type":"span","marks":[],"text":" Delusions are environment-driven and closely correlate with the degree of the individual’s disorganization. Anecdotally, this writer has observed a patient reporting delusions of misidentification, that security staff have been replaced by family members connected to the patient’s instant offense, and another patient endorsing ideas of reference from the static generated by the security staff’s radios.","_key":"6d2f60bbc157"}],"_type":"block","style":"normal","_key":"f8cd5908d610"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Another relatively common pattern of malingering involves feigning cognitive symptoms. Individuals in forensic or correctional facilities awaiting competency evaluations can grossly exaggerate cognitive deficits to undergo transfer to a civil facility or plead insanity to avoid long periods of incarceration.","_key":"f702833e330e0"},{"_type":"span","marks":["superscript"],"text":"16","_key":"4a49cc61d016"},{"_type":"span","marks":[],"text":" In such instances, psychometric testing such as performance and symptom validity testing has been shown to be highly specific in detecting feigning. Furthermore, incarcerated individuals can also malinger suicidal ideation to be transferred to community hospitals or forensic facilities for psychiatric stabilization.","_key":"41a53c91033f"},{"marks":["superscript"],"text":"17","_key":"a139bb246c93","_type":"span"}],"_type":"block","style":"normal","_key":"223963a7c9e0"},{"style":"normal","_key":"9bb1d124ffa6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"995dc69c62ea0"}],"_type":"block"},{"_type":"block","style":"normal","_key":"44427ae53e99","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts (and Myths) to Consider","_key":"71c44b1e52720"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Forensic and correctional settings prove to be ripe environments for malingering symptoms, especially of mental illnesses. However, the consideration and investigation of malingering must be done with exquisite caution, as it can worsen stigma and result in individuals not getting much-needed interventions. When making the diagnosis, a complete evaluation combined with psychological testing and collateral information from sources such as staff, previous records, and even family must be carefully weighed along with clinical judgement. There is a wealth of literature on interview techniques and indicators to consider when suspecting malingering.","_key":"85b59ab745370"}],"_type":"block","style":"normal","_key":"b1c541349f0b"},{"style":"normal","_key":"558e7d3104a1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Individuals who feign symptoms can have prior mental illnesses, and this does not preclude malingering. The reporting of purely atypical symptoms does not default to malingering as well. Another commonly encountered trope is that individuals diagnosed with antisocial personality disorder have a higher propensity to malinger, and this has been proven to be false across many bodies of research. On a final note, diagnosing malingering can include dire consequences such as loss of much-needed privileges and sentencing enhancements, and therefore, it is best to view it as the diagnosis of exclusion, within the diagnosis of exclusion that is psychiatry.","_key":"1ca09bab06250"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"","_key":"7ae391e4285c0"}],"_type":"block","style":"normal","_key":"5e4d0f20fb67","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Kumar ","_key":"a44d790c922c0"},{"_type":"span","marks":["em"],"text":"is an early career forensic psychiatrist. He is an attending physician at a State forensic facility for the New York Office of Mental Health.","_key":"a44d790c922c1"}],"_type":"block","style":"normal","_key":"919933cb73c6"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"095b4ac91f760"}],"_type":"block","style":"normal","_key":"9cdfa29e5984"},{"_key":"1107d0845292","markDefs":[],"children":[{"_key":"c875c46b28060","_type":"span","marks":["strong"],"text":"References"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"1. Carson A. Prisons report series: preliminary data release. Bureau of Justice Statistics. September 2023. Accessed October 23, 2024. ","_key":"59680a53f8bb0"},{"_type":"span","marks":["667850a10981"],"text":"https://bjs.ojp.gov/library/publications/prisons-report-series-preliminary-data-release","_key":"59680a53f8bb1"}],"_type":"block","style":"normal","_key":"569750e32e3b","markDefs":[{"blank":true,"_type":"link","href":"https://bjs.ojp.gov/library/publications/prisons-report-series-preliminary-data-release","_key":"667850a10981"}]},{"_key":"3eba990edb35","markDefs":[{"_key":"32d1c02371b7","blank":true,"_type":"link","href":"https://www.statista.com/statistics/262962/countries-with-the-most-prisoners-per-100-000-inhabitants/"}],"children":[{"_type":"span","marks":[],"text":"2. Countries with the largest number of prisoners per 100,000 of the national population, as of January 2024. Statista. January 2024. Accessed October 23, 2024. ","_key":"e208ec02f6ba0"},{"_type":"span","marks":["32d1c02371b7"],"text":"https://www.statista.com/statistics/262962/countries-with-the-most-prisoners-per-100-000-inhabitants/","_key":"e208ec02f6ba1"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"3. Kim DY. Psychiatric deinstitutionalization and prison population growth: a critical literature review and its implications. ","_key":"3feb449f137b0"},{"_type":"span","marks":["em"],"text":"Criminal Justice Policy Review","_key":"3feb449f137b1"},{"_type":"span","marks":[],"text":". 2014;27(1):3-21.","_key":"3feb449f137b2"}],"_type":"block","style":"normal","_key":"8fb61420ffe2","markDefs":[]},{"style":"normal","_key":"d793a5543aef","markDefs":[{"blank":true,"_type":"link","href":"https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2765271","_key":"145fd847b1b2"}],"children":[{"_type":"span","marks":[],"text":"4. Hawks L, Woolhandler S, McCormick D. ","_key":"2a8f176fe80f0"},{"_type":"span","marks":["145fd847b1b2"],"text":"COVID-19 in prisons and jails in the United States.","_key":"2a8f176fe80f1"},{"_type":"span","marks":[],"text":" ","_key":"f5bd0559a36e"},{"_key":"2a8f176fe80f2","_type":"span","marks":["em"],"text":"JAMA Intern Med"},{"_type":"span","marks":[],"text":". 2020;180(8):1041-1042.","_key":"2a8f176fe80f3"}],"_type":"block"},{"_type":"block","style":"normal","_key":"d3921d5b02d5","markDefs":[],"children":[{"marks":[],"text":"5. Resnick P, Knoll J, Bender SD, Rogers R. In: Rogers R, Bender SD. ","_key":"041f921951bf0","_type":"span"},{"_type":"span","marks":["em"],"text":"Clinical Assessment of Malingering and Deception.","_key":"041f921951bf1"},{"_type":"span","marks":[],"text":" 4th ed. The Guilford Press; 2020.","_key":"041f921951bf2"}]},{"style":"normal","_key":"813ce7150c21","markDefs":[{"_key":"e543f7610045","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18583690/"}],"children":[{"_key":"b23346e4635d0","_type":"span","marks":[],"text":"6. Stone AA. "},{"_type":"span","marks":["e543f7610045"],"text":"The ethical boundaries of forensic psychiatry: a view from the ivory tower. Bull Am Acad Psychiatry Law 12:209-19, 1984.","_key":"b23346e4635d1"},{"_type":"span","marks":[],"text":" ","_key":"9a440cb8ffd7"},{"_type":"span","marks":["em"],"text":"J Am Acad Psychiatry Law","_key":"b23346e4635d2"},{"_key":"b23346e4635d3","_type":"span","marks":[],"text":". 2008;36(2):167-174."}],"_type":"block"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/9323651/","_key":"b8299a87ee79"}],"children":[{"_type":"span","marks":[],"text":"7. Appelbaum PS. ","_key":"9b4a430b96400"},{"_type":"span","marks":["b8299a87ee79"],"text":"A theory of ethics for forensic psychiatry.","_key":"9b4a430b96401"},{"marks":[],"text":" ","_key":"9664e84b8a17","_type":"span"},{"_key":"9b4a430b96402","_type":"span","marks":["em"],"text":"J Am Acad Psychiatry Law"},{"marks":[],"text":". 1997;25(3):233-247.","_key":"9b4a430b96403","_type":"span"}],"_type":"block","style":"normal","_key":"a80f21904524"},{"children":[{"_type":"span","marks":[],"text":"8. Ethics Guidelines for the Practice of Forensic Psychiatry. American Academy of Psychiatry and the Law. May 2005. Accessed October 23, 2024. ","_key":"1dd1ef3e45720"},{"_key":"1dd1ef3e45721","_type":"span","marks":["0dbe9a20e7d5"],"text":"https://www.aapl.org/ethics.htm"}],"_type":"block","style":"normal","_key":"83745509f704","markDefs":[{"blank":true,"_type":"link","href":"https://www.aapl.org/ethics.htm","_key":"0dbe9a20e7d5"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/17058121/","_key":"7bd4fcb7fc3f"}],"children":[{"marks":[],"text":"9. Vitacco MJ, Rogers R, Gabel J, Munizza J. ","_key":"de37d84c20450","_type":"span"},{"_type":"span","marks":["7bd4fcb7fc3f"],"text":"An evaluation of malingering screens with competency to stand trial patients: a known-groups comparison.","_key":"de37d84c20451"},{"marks":[],"text":" ","_key":"219aebda2344","_type":"span"},{"_type":"span","marks":["em"],"text":"Law Hum Behav","_key":"de37d84c20452"},{"_key":"de37d84c20453","_type":"span","marks":[],"text":". 2007;31(3):249-260."}],"_type":"block","style":"normal","_key":"ca9a3289bd08"},{"style":"normal","_key":"7deed793bb77","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/23664364/","_key":"97baab8f7994"}],"children":[{"_type":"span","marks":[],"text":"10. McDermott BE, Dualan IV, Scott CL. ","_key":"e3ee1cd8ce7e0"},{"_type":"span","marks":["97baab8f7994"],"text":"Malingering in the correctional system: does incentive affect prevalence?","_key":"e3ee1cd8ce7e1"},{"_type":"span","marks":[],"text":" ","_key":"4577c8ecab21"},{"text":"Int J Law Psychiatry","_key":"e3ee1cd8ce7e2","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2013;36(3-4):287-292.","_key":"e3ee1cd8ce7e3"}],"_type":"block"},{"_key":"1ade6a6f0d57","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/32237983/","_key":"a29e82413d01"}],"children":[{"_key":"4c39094eb3500","_type":"span","marks":[],"text":"11. Pinals DA, Callahan L. 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