Maryland Pao, MD

“Brain activity can be understood, that is, has meaning, only to the extent that it is a representation of the state of the body, of the external world, or of a potential behavior. Just as it would be pointless to analyze a book by investigating the chemical composition of paper and ink, a reductionist analysis of brain activity, that is, taking it apart and analyzing its nucleic acids, enzymes, receptors, and ion channels, fails to explain what brain activity accomplishes. The neuroscience of meaning requires experiments that study brain activity as the body moves through the world or as people describe their experience.”

- Howard Fields, Setting the Stage for Pain: Allegorical Tales From Neuroscience

The English word pain is derived from the Latin word poena, meaning penalty or punishment. Because of the intrinsically intimate and subjective nature of pain, philosophers and medical providers struggle to find a definitive definition of the word. It is variable through references, authors, and times, with conceptualizations focusing alternately on the biomedical, emotional, or behavioral components of the phenomenon. The philosopher René Descartes’ mechanistic conceptualization of pain as a sensation, where the animal merely reacts to the noxious stimulus, dominated scientific and folk beliefs about pain into the mid-20th century.

 The more modern emergence of the concept of being-in-pain, which includes the subjectivity of the individual in the experience, opens the door for a bigger involvement of mental health professionals in pain management.

 International Association for the Study of Pain

 coined a new definition of pain in 1979: “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

 This flexible definition acknowledges the sensory, cognitive, affective, and motivational processes that influence the experience of pain and allows for a broader exploration of its subjectivity. It trades a purely neurological view for a more holistic conceptualization that considers the totality of the pain and, more importantly, of the patient.

The differentiation between acute and chronic pain has proven to be clinically useful for tailoring interventions. Traditionally, the distinction between acute and chronic pain has relied upon a single continuum of time, with the designation of an arbitrary interval as a transition point, most commonly between 3 and 6 months. Another way to characterize chronic pain is pain that extends beyond the expected period of healing—assuming one knows what that should be.

Both acute and chronic pain are major public health problems with high health care costs and resource requirements. According to a 

, the conservative estimate of the health care cost of pain is around $560 to $635 billion annually, which is significantly greater than that of heart disease, cancer, or even diabetes mellitus.

 Because of this high prevalence and significant morbidity, pain has earned the designation of “the fifth vital sign.”

Despite these tremendous expenses and heroic efforts (using sophisticated technology, biomedical advances, and ever-growing research), most pain conditions have no final options for a cure. The only potent analgesics available are opioids, which can be problematic given the current opioid epidemic in Western countries. However, with the broader and multifaceted understanding of pain, patient care has moved from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient. To achieve this goal, the clinical integration of mental health providers in pain management teams has become more widespread.

The Relationship Between the Experience of Pain and Mental Health

If we agree with Ludwig Wittgenstein, PhD, who posited that “words are connected with the primitive, the natural expressions of the sensations and are used in their place,”

 it is not hard to see that even in the everyday language about pain, there exists a significant overlap between the purely physical experience of pain and the consequent subjective emotional aspects that arise with it. It might even seem that the connection transcends all elaborate philosophical theories and is deeply felt and expressed on an instinctual level. The most obvious example of the connection is that expressions like “broken-hearted” or “a slap in the face” are often used in multiple languages to describe experiences of physical as well as emotional, psychological, or even spiritual suffering.

This intimate and intricate relationship is also well understood even if one chooses to look at it from a purely neurobiological perspective. Although pain might initially originate from peripheral sensory receptors, the experience of pain is not complete without the 

modulatory involvement of the central nervous system

 Afferent stimuli from the thalamus, the limbic system, and cortical structures like the frontal lobe and the somatosensory cortex amplify or diminish the peripheral painful stimuli and add a subjective emotional component to the sensation. Functional imaging techniques and direct brain stimulation studies have demonstrated a striking overlap between central structures implicated in the 

 In addition, recent studies have described how chronic pain changes grey matter in the brain, resulting in secondary psychiatric symptoms and disorders. These studies thus emphasize a 

Figure 1. Common Brain Areas Implicated in Both Pain and Pleasure Processing

An individual’s experience of pain cannot be understood in a sterile context. With this conceptualization comes the possibility of applying psychological principles to the treatment of pain. Cognitive behavioral theories of pain are based on the premise that cognitions, emotions, behaviors, and physical sensations are all interrelated and exist within a particular context.

 Psychologists observe that changes in any of these areas can have wide-ranging influences through a circular effect on each other.

 illustrates how the different components of cognitive behavioral therapy (CBT) interact with each other to create vicious cycles, which in turn can cause a clinical increase in symptoms. From an interpersonal perspective, it is also clear that persistent personality traits can influence the subjective experience and expression of pain. Specific defensive and coping styles in an individual may create a particular and sometimes 

 Finally, although there is limited interest in the psychodynamic perspective of pain, multiple authors have argued that patients communicate on multiple conscious and unconscious levels through bodily manifestations, and that pain expressions hold 

 that warrant psychological and psychoanalytic exploration.

Figure 2. The Application of Cognitive-Behavioral Theory on the Experience of Pain

The Empirical Evidence for an Interdisciplinary Approach to Chronic Pain

From a more practical standpoint, evidence-based medicine shows a significant association between pain and mental health disorders and symptoms. There exists a statistically important comorbidity between acute and chronic pain and depressive disorders, anxiety disorders, substance use disorders, and personality disorders.

 Empirical evidence shows higher efficacy for the multidisciplinary and interdisciplinary management of pain that is based on the biopsychosocial model, which combines physical therapy, pain management by medication, patient education, ergonomic training, psychiatric treatment, and psychotherapy, among others. These interventions have shown significant results on the ratings of pain intensity scores, as well as on the quality-of-life measures that encompass both mental health and the functional impacts.

The Role of the Consultation-Liaison Psychiatrist in the Management of Pain

Consultation-liaison (C-L) psychiatrists are key members and leaders of interdisciplinary pain management teams. Psychiatry residents get the most 

 during the substance abuse/addictions (60%) and the C-L psychiatry (57%) rotations.

C-L psychiatrists are uniquely qualified to help patients with pain and play an important role in the pain management team. Although most primary care physicians and medical specialists can diagnose and initiate the treatment of psychiatric disorders, C-L subspecialists can diagnose more subtle and complex mood or anxiety disorders, substance use disorders, or personality disorders in a general medical setting. They can also participate in the pharmacological and even interventional management of pain, detect possible drug-drug interactions in these medically complex patients, and screen for possible medication side effects.

In addition, as the name of the specialty reveals, C-L psychiatrists are experts in bridging the gap between the patient and the other medical teams. They can relay messages in an empathic and understanding way and bring the goals of treatment into alignment with the patient’s values, preferences, and styles. Their integrated view of patients allows for reflection on behavioral, interpersonal, and psychodynamic formulations of the patient’s pain experience that can be communicated to the team to personalize the treatment and thus improve the quality of the care. 

 details the separate and overlapping roles of the pain specialist and the C-L psychiatrist.

Figure 3. The Separate and Overlapping Roles of the Pain Specialist and the Consultation Liaison Psychiatrist

Exploring the Future of C-L Psychiatry Within Pain Management Teams

 showed a national improvement of pain education in psychiatry training.

 The investigators found that more than two-thirds (70%) of program directors supported having psychiatry residents receive education and training in chronic pain management. This is a significant improvement from the less than 50% found in the 

The increase in pain management education is not limited to psychiatry residency; it also currently includes more continuing medical education (CME) focused on psychiatric aspects of pain, medication management of pain, meditation, CBT, and other strategies.

 This is particularly true for C-L psychiatrists, whose national professional organization, the 

Academy of Consultation-Liaison Psychiatry

, specifically includes CME for chronic pain as well as special interest groups for palliative medicine, addiction and toxicology, and collaborative and integrated care, among others.

Overall, the future of this integrated approach to pain with the inclusion of C-L psychiatrists looks bright. Encouraging systemic changes are starting to occur, including changes to reimbursement for medical services (meaning procedural and nonprocedural pain interventions will be more equally compensated). They also include changes to the referral processes between specialists, making the processes more efficient and allowing the emergence of bigger interdisciplinary teams.

We believe that an integrated treatment actively involves C-L psychiatry which, in the words of 

, constitutes the final missing P in the management of pain,

 and which can significantly improve health outcomes and the quality of life of this patient population.

is a consultation-liaison psychiatrist and palliative care fellow at MedStar Washington Hospital Center in Washington, DC.

is clinical and deputy scientific director of the National Institute of Mental Health and the National Institutes of Health, and acting clinical director of the National Center for Complementary and Integrative Health, all in Bethesda, MD.

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The economic costs of pain in the United States

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Noncancer pain conditions and risk of suicide

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Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes

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Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation

The status of pain medicine education in psychiatry: a survey of residency training program directors

17. Majeed MH, Ali AA, Metzger S, Sudak DM. 

Pain management education and training during psychiatry residency: a report on national progress

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The role of psychiatric education in pain management

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The missing p in psychiatric training: why it is important to teach pain to psychiatrists

Articles

With a broader and multifaceted understanding of pain, patient care can move from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient.

The Final “P” in Pain Management

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Suicide is a global public health crisis and is the 

 In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than 2-fold. Moreover, suicide risk is even higher among individuals with comorbid medical illnesses. Illness such as cancer, diabetes, and asthma have all been shown to increase risk for suicide.

 Given that medical illness is a concerning suicide risk factor, medical settings provide an optimal venue for suicide risk detection and intervention.

Medical settings are well positioned to detect suicide risk. The majority of people who died by suicide visited a health care professional months before their death, placing medical providers on the frontlines of suicide risk detection and suicide prevention.

 However, many patients with suicidal thoughts who present to the health care system with somatic complaints do not disclose suicidal thinking unless asked directly, and most medical settings do not screen for suicide risk.

Notably, suicides in the hospital are one of the top 5 most frequently 

sentinel events to The Joint Commission (TJC).

 Many are surprised to learn that although in-hospital suicides are relatively rare for patients undergoing general medical care, a sizeable portion of them occur on non-behavioral health units, such as intensive care units or emergency departments (EDs). Given these striking statistics and the goal of leveraging hospitals as partners in suicide prevention, TJC revised National Patient Safety Goal 15.01.01 (NPSG 15) in 2019.

 NPSG 15 outlines several elements to optimize patient safety and the reduction of suicide risk in medical settings. In particular, NPSG 

performing environmental safety assessments, removing ligature risks, screening patients with behavioral health issues for suicide risk, and providing further assessment of at-risk individuals who screen positive.

 Although NPSG 15 refers to suicide risk screening of all patients who are being treated or evaluated for a behavioral health condition as their primary reason for care, the TJC issued Sentinel Event Alert 56 in 2016, recommending suicide risk screening for all patients, using brief, evidence-based screening tools.

Following these recommendations, a growing number of health care systems have implemented suicide risk screening programs for all patients, including those presenting with medical complaints. Such a program at 

 (PHHS) is an example of how to successfully implement hospital-wide universal suicide risk screening. Using one of the screening tools recommended by TJC, PHHS screened more than 325,000 patients in the first 6 months of implementing their screening program and detected a positive screen rate of below 4% among patients undergoing medical care.

 It will be important for hospitals to work with frontline clinicians to develop safe and feasible procedures for implementing the safety guidelines outlined in NPSG 15 across diverse rural and urban settings and to be able to articulate their procedures to TJC surveyors when they assess hospitals for safe care delivery.

Several suicide risk screening tools are commonly used, with varying levels of evidence to support their use among these patients. Thom and colleagues

 reviewed several brief suicide risk screening tools and discussed the benefits and limitations of each for use in a hospital setting.

 Their review discusses 6 screening tools, including the Ask Suicide-Screening Questions (ASQ), the Patient Safety Screener (PSS-3), and the Columbia-Suicide Severity Rating Scale (C-SSRS), most of which are also TJC-recommended screening tools.

 The authors highlighted that only 2 of the tools discussed, the ASQ and the PSS-3, were developed and validated specifically for patients undergoing medical care.

Notably, the C-SSRS, a tool used by many hospitals due to its application to both youth and adults, has not been validated specifically for use in medical settings. Although Thom and colleagues highlighted that no suicide risk screening tools have been validated for use among both pediatric and adult patients undergoing medical care, recent data show that the ASQ, originally validated for use among youth, also has excellent psychometric properties among adult medical patients, potentially allowing for the use of 1 screening tool across hospitals.

Some medical settings utilize depression screeners to identify patients at risk for suicide. For example, the Patient Health Questionnaire (PHQ-9), which is an excellent depression screen, is sometimes utilized as a suicide-risk screening tool.

 Although there is a well-documented association between suicide and depression, extant research shows that the 2 are not synonymous. In 1 study, 90% of suicide decedents met criteria for diagnosis of a mental illness; however, only 28% of suicide decedents met the criteria for major depressive disorder.

 Moreover, screening solely for depression in patients undergoing medical care may not adequately detect suicidal ideation.

Question 9 on the PHQ-9, which asks about the frequency of a patient being bothered by “thoughts that you would be better off dead, or of hurting yourself in some way,” contains both an “or” and the word hurting instead of killing. Some studies have used this item to identify large numbers of at-risk patients.

However, specific concerns exist regarding the sensitivity and specificity of item 9

; the awkward wording of the question leading to inaccurate responses

; and that relying solely on item 9 may miss a large portion of patients at risk for suicide.

Using depression screeners such as the PHQ-9 as a proxy for suicide risk screening may be insufficient to detect suicide risk. Additionally, other mental health disorders, such as substance use disorders, schizophrenia, and anxiety disorders are associated with risk of suicide, which would go undetected by screening only for depression.

 Asking directly about suicide risk and using validated tools specific to hospital settings is necessary to accurately screen for suicide risk.

risk screening tools that was created and tested specifically for use among patients undergoing medical care, the ASQ is also part of a 3-tiered suicide risk screening clinical pathway.

 Although this pathway was designed for use among youth, the 3-tiered system can be applied to all such patients, including adults. The proposed pathway starts with the use of a brief screening instrument to rapidly screen all medical patients for suicide risk. For this step, Brahmbhatt and colleagues

 recommended the use of the ASQ due to its brevity and focus on patients undergoing medical care. The PSS-3 is the other screening tool that has been tested on adult patients in the ED and makes an excellent first-line brief screener.

After a patient screens positive for suicide risk, the second and essential step is to have a trained clinician (eg, a mental health clinician, nurse practitioner, physician assistant, primary care physicians) conduct a 10- to 15-minute brief suicide safety assessment (BSSA) to determine how to effectively manage the patient’s suicide risk. The secondary safety assessment step was created to avoid a one-size-fits-all planfor anyone who screens positive on a primary screener. All positive screens should not be treated as an 

; in fact, the majority of positive screens will be non-acute positives that do not require full safety precautions, but rather need further assessment.

This second step helps to ensure that mental health resources are used effectively and patients who reveal suicidal thoughts are not treated in a way that may seem punishing. For the BSSA, the clinical pathway published by Brahmbhatt and colleagues suggested the C-SSRS or the ASQ BSSA. Anecdotal evidence from frontline screeners suggests that the C-SSRS, which is a good in-depth suicide risk severity rating scale, is lengthy as a first-line screener and is more appropriate as a secondary suicide safety assessment tool for use among patients who screen positive for suicide risk. The ASQ and the ASQ BSSA are available as part of the ASQ Toolkit.

 The aim of the BSSA is to help a clinician further assess suicide risk in order to determine next steps in the pathway—whether a full mental health evaluation is needed at that particular medical visit, or if it can wait for an outpatient mental health referral.

Following a positive suicide risk screen, an essential component of ensuring patient safety is safety planning and lethal means counseling. Stanley and Brown

 published a safety plan worksheet that can help clinicians assist patients in planning how they will handle a future suicidal crisis. This worksheet consists of 6 steps that includes identifying personal warning signs, internal coping strategies, people and settings that can provide distraction, trusted people who can provide help, contact information for mental health resources, and ways to make the environment safe. The last step refers to the process of lethal means safety counseling, which is a detailed discussion on how to limit access, remove, or safely store dangerous items (eg, pills, firearms, knives, and ropes).

Implementation of suicide risk screening has been a specific challenge for many hospital systems due to difficulty selecting an evidence-based tool across the lifespan and across medical/surgical specialty settings that work in both inpatient and outpatient settings. In addition, guidance around how positive screens should be interpreted have led to systems developing untenable rules, such as “all positive screens require 1-to-1 sitters” and “strict safety precautions.”

In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than two-fold.

Somewhat surprisingly, the rate of positives screen results due to reporting a past suicide attempts is significant. Past suicidal behavior is one of the most predictive risk factors of future behavior, but many reported attempts were in the distant past (eg, more than 10 years earlier). How should these truthful responses be interpreted? Such past behavior may be important clinical history when delivering a poor medical prognosis to a patient. Clearly more implementation research is needed on how to handle past attempt history and how frequently patients should be screened.

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Due to the urgent need, we revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone 

Typically, anyone who is in imminent danger requires an urgent psychiatric evaluation in an ED. The pathway needed to be revised to help patients with acute suicide risk avoid exposure to COVID-19 in the ED and to spare the ED from over-crowding during the pandemic crisis. Separate adult and youth versions of this 

were created and are available as part of the ASQ Toolkit (

 However, they have not yet been empirically tested. A critical part of this pathway is for the health care practitioner to provide 

 to the patient and family members or friends to ensure safe storage or removal of potentially dangerous items (eg, pills, firearms, belts, knives).

Detection and management of suicide risk screening in the medical setting is no longer theoretical. There are many hospitals successfully implementing suicide-risk screening programs with validated instruments. Universal suicide risk screening can be successfully implemented without incurring a need for additional resources. Use of the intermediate step of a brief suicide safety assessment provides critical guidance for determining appropriate follow up in a safe and efficient manner. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral. With evidence-based tools and pathways to guide them, every health care provider can be a partner in suicide prevention.

is the Clinical Director of the National Institute of Mental Health (NIMH) Intramural Research Program at the National Institutes of Health, she is also the Deputy Scientific Director, NIMH; 

is an Intramural Research Training Award Fellow at the NIMH; 

 is a Staff Scientist and Clinical Psychologist at the National Institute of Mental Health Intramural Research Program at the National Institutes of Health, she also serves as a senior attending with a specialty in pediatric psychology on the Psychiatry Consultation Liaison Service in the Hatfield Clinical Research Center at NIH.

Acknowledgement—This research was supported in part by the Intramural Research Program of the NIMH (Annual Report Number ZIAMH002922).

1. CDC National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System (WISQARS). 

2. Karmakar C, Luo W, Tran T, et al. Predicting risk of suicide attempt using history of physical illnesses from electronic medical records. 

3. Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. 

4. Pan YJ, Lee MB, Chiang HC, Liao, SC. The recognition of diagnosable psychiatric disorders in suicide cases’ last medical contacts. 

5. Frankenfield DL, Keyl PM, Gielen A, et al. Adolescent patients”: healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. 

6. The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. 

https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

7. The Joint Commission. Hospital National Patient Safety Goals. NPSG.15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf

8. The Joint Commission. Detecting and treating suicide ideation in all settings. 

9. Roaten K, Johnson C, Genzel R, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. 

10. Thom R, Hogan C, Hazen E. Suicide-risk screening in the hospital setting: A review of brief validated tools. 

11. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. 

12. Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide-risk screener for emergency department settings. 

13. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. 

14. The Joint Commission. Validated/ Evidence-Based Screening Tools. Suicide Prevention Resources to support Joint Commission Accredited organizations implementation of NPSG 15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/suicide_prevention_resources_ep2_npsg150101.pdf

15. Horowitz LM, Snyder DJ, Boudreaux ED, et al. Validation of the Ask Suicide-Screening Questions (ASQ) for adult medical inpatients: a brief tool for all ages. 

16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. 

17. Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. 

18. Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer. 

19. Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. 

20. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? 

21. Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. 

22. Suarez L, Beach SR, Moore SV, et al. Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease. 

23. Razykov I, Hudson M, Baron M, Thombs BD. Utility of the Patient Health Questionnaire?9 to assess suicide risk in patients with systemic sclerosis. 

24. Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? 

25. Dueweke AR, Marin MS, Sparkman DJ, Bridges AJ. Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients. 

26. Brahmbhatt K, Kurtz BP, Afzal KI, et al. Suicide-risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. 

27. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit, 2017. 

28. Stanley B, Brown GK. Safety Planning Intervention: a brief intervention to mitigate suicide risk. 

The authors share evidence-based guidance for patient safety that minimizes suicide risk in medical settings.

Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings

A. State you cannot work with him if he discontinues his medication

B. Contact his parents to bring them into the next session to discuss concerns about medication nonadherence

C. Review indications and informed consent for each medication to understand his history of treatment and current ambivalence

D. Agree to discontinue medications if he appears stable and keep close clinical watch while building a therapeutic alliance

It is common for young adults to express a desire to discontinue medications taken since childhood.

To encourage treatment adherence, it is appropriate to redo the informed consent process and review indications for each medication. This will remind the patient of how a medication can help him in functioning and reaching goals.

Because the effects and adverse effects that the patient's parents or guardian agreed to in the past may no longer be acceptable, it is important to present the risks and benefits of each medication.

Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Challenges of Transitioning From Pediatric to Adult-Oriented Care

,” by Margaret J. Yoon, MD and Maryland Pao, MD, on which this quiz was based.

Poll

A 19-year-old new patient comes to you wanting to discontinue all his childhood psychiatric medications. What is the best next step?

Mini Quiz: New Patient Consult

Young adult psychiatry addresses the needs of transitional-age youth typically between the ages of 15 and 26 years. The phenomena of transitional age difficulties are a result of cultural and societal changes in which physiologic maturity (as marked by chronological age and biological development) and the acquisition of skills necessary for independent adult life in modern society are not aligned; this may be due to chronic illness in childhood, which is on the rise, or changes in parenting or other psychosocial difficulties. Society is confused about the roles and responsibilities of youth, as noted by Giedd:

Age-of-consent questions are particularly enmeshed in political and social contexts. For example, currently in the United States a person must be at least 15 to 17 years old . . . to drive, at least 18 to vote, buy cigarettes, or be in the military, and at least 21 to drink alcohol. The minimum age for holding political office varies . . . some municipalities allow mayors as young as 16 . . . , governors from 18 to 30. The age of consent to sexual relations varies worldwide from puberty . . . to age 18.

The inverse situation is illustrated in the legal entity of emancipated minors, which recognizes certain youth as developmentally or functionally advanced beyond their chronological age of less than 18 years once they demonstrate certain adult competencies (eg, financial self-sufficiency, marriage, caretaking of children, military service).

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Disorders from childhood and adolescence, such as ADHD and autism spectrum disorders, continue to affect function, but at a higher degree that cannot be as easily accommodated by families and educational or therapeutic systems. Popular expressions such as “extended adolescence” or “failure to launch” focus concern on the individual’s deficits, but it is important to consider a developmental perspective that recognizes the challenges of the family and the clinical system in transitioning youth as well. So, who is responsible for treating the adolescent and young adult and when and how should transitions in care occur?

When to refer a young patient to an adult psychiatrist

Child and adolescent psychiatrists practice within a moving developmental frame and may work with adolescents and young adults as they enter adulthood for continuity of care. However, pediatric psychiatrists may choose to refer the patient to an adult psychiatrist for several reasons. The volume of emerging young adults would quickly saturate pediatric providers’ patient load. Educational or employment transitions can result in a geographic move that makes access to childhood providers difficult. Child and adolescent psychiatrists may treat multiple members of a family, and referral to another clinician may help separation and foster the patient’s individuation process.

When a patient is reluctant to transition to adult services, pediatric psychiatrists may recognize dynamics that resist change to the treatment configuration, such as avoidance due to anxiety about more independent functioning, leaving an established doctor-patient relationship, unacknowledged dependence on the family support that pediatric treatment providers offer, and reaction to an enactment of parental loss or abandonment. With support, the patient can be guided through the sense of loss and normal grief in such a transition. Thus, planning for the transition, on the part of the child psychiatrist as well as the receiving adult psychiatrist, requires forethought as much as a year before the actual transition if possible.

Issues in accepting transitioning patients

When adult providers begin to work with adolescents and young adults and their families who have transitioned from child psychiatry, reviewing confidentiality and setting treatment boundaries avoid confusion between the treatment models. Pediatric psychiatrists operate with a family-informed developmental model that may incorporate routine communication with parents to direct supportive changes in the home. Families may have the expectation that their child’s treating psychiatrist will freely release information. A review of confidentiality policies at the first meeting should outline how information (that will be more regulated in its release and with the child’s permission) will be exchanged by the adult psychiatrist with the family.

As children negotiate their own space apart from parents, there may be a greater need to establish clear boundaries. Information-gathering meetings with the family should be discussed beforehand with patients to define the level of disclosure and role of the session. Family sessions may also be balanced with separate meetings with significant others and families of choice, as this recognizes the importance of extra-familial relationships and invites other adult perspectives on a patient’s history.

Developmental discontinuity to adult functioning

There are several situations that can hinder a smooth segue to adult functioning. Young adulthood is a period when mood or psychotic disorders may first present, and it may be a difficult, clinically unstable period. For youths who have had periods of severe symptomatology, their caretakers may have provided too much accommodation out of a sense of overprotection, thereby enabling avoidance of challenges during adolescence. Consequently, these youths may not have had opportunities to develop skills to function autonomously, and they may stall from anxiety or regress when adult expectations are placed on them.

Alternately, if an adolescent received inadequate supervision, there may be hidden or minimized development of symptoms that worsened with disengagement from treatment. With the additional loss of parental support at 18, these youths fall off the treatment radar until nonadherence results in relapse. With decreased supervision, young adults may have increased access to settings where recreational drugs are available, just as they have also reached the legal age limit for the purchase of alcohol. Some vulnerable youth may have undertreated substance abuse or be self-treating mood and anxiety symptoms with substances, all of which can undermine appropriate adult coping.

Not every young person has mastered skills of independent functioning by the age of 18, so the transitional age range reflects the discontinuity that can appear between chronological age and developmental maturity. Some families (such as those with high-conflict divorces or another family member with chronic illness) may be dependent on the child’s presence or other benefits they bring to the household, and the family destabilizes when the adolescent attempts to functionally individuate or leave. The young adult experiences himself or herself as the cause of the family’s distress and delays transitioning in order to stabilize the family.

J is a 17-year-old high-performing junior at a competitive high school when she presents for psychiatric care for acute MDD with suicidal ideation and prominent anxiety features, in the context of increasing academic demands, declining grades, new-onset self-injury, and social withdrawal. She requires 2 inpatient hospitalizations for recurrent suicidal ideation of jumping in front of the subway en route to school.

Her distress decreases as academic adjustments are discussed, antidepressant medication is initiated, and her parents agree to therapeutic support for her. However, she has difficulty stepping down to a partial hospitalization program as she finds family meetings hard to tolerate because of the high level of tension between her parents, and she is often absent from the program the day after family meetings. She engages in individual outpatient medication management and psychotherapy more easily but is nonverbal or angry during periodic family sessions. This is followed by worsening urges for self-injury and thoughts of self-denigration and punishment.

J is unable to return for her senior year in high school because of exacerbation of symptoms, and she ambivalently receives home instruction. She continues in outpatient treatment, but with no clear progress developmentally or educationally.

After several months, J discloses in therapy that there is longstanding, mutual physical domestic violence between her parents, and she is frequently drawn into the fights in her attempts to stop their conflicts. She is concerned about her mother’s apparent depression and her father’s dissociative reactions after fights.

It is identified that the mother’s strong positive transference to J’s individual therapist has been particularly helpful in opening up the parents to treatment, but this secret has never been revealed outside the home. J realizes her perfectionism and academic excellence had initially served to refocus her parents and reduced the number of fights at home in her early years, and now the onset of her MDD and academic failure serves the same purpose. She states that she is afraid to leave home for fear that without her presence and intervention, her parents could inadvertently disable or kill each other.

After a discussion with the entire family, child protective services is contacted and the report is filed with a concurrent request from the parents for voluntary home-based services. The parents also agree to begin couples’ therapy to address relationship dynamics that existed before J was born, and to start to consider individual treatment. This allows J to release some of the caretaking and sense of responsibility she has toward her parents. J chooses to pursue her senior year of high school at a therapeutic boarding school that offers support for her anxiety and depression symptoms, and she is able to consider applying to local colleges.

As J’s 18th birthday approaches, transition to adult care is discussed with her and her parents. Although J has a strong therapeutic alliance with her adolescent psychiatrist and psychotherapist who have worked with her since her first hospitalization, she expresses a desire to find treatment closer to her boarding school and to separate from those who are working collaboratively with her parents. She feels that her parents will continue to struggle with safety in their relationship; although she restricts communication, her mother continues to leave messages for J’s therapist.

Several options that accept J’s insurance are identified and discussed with her over several months. She chooses an adult mental health center that offers group therapy options and specialized treatment for trauma. She allows communication between her pediatric and new adult teams, but restricts communication with her parents despite their expressed preference. She successfully transitions to living in a dorm at a college within the state but outside of her hometown.

Because adolescents and young adults have experience with pediatric providers who use a range of developmental approaches and may be family focused, transition-age patients are usually more comfortable with a practical, emotionally “real” therapeutic engagement with adult therapists. Changes in continuity of care are always challenging. When providing care to transitional patients, consider selective, therapeutically appropriate emotional disclosure during initial sessions to convey your concern, worry, or interest to foster the patient’s engagement and trust.

Building a quick alliance by joining a rejecting stance toward the family of origin is equivalent to building on sand, because this serves to externalize blame and erodes opportunities for reflection and practicing mature responsibility. This also sets up a framework for the projection of blame onto other responsible adults in the young adult’s life, such as bosses, teachers, and friends, which may later extend to the new therapist.

Who is responsible for treating the adolescent and young adult with psychiatric issues -- and when and how should transitions in care occur? 

Maryland Pao, MD

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