Dr. Sharma is a Geriatric Psychiatry Fellow, Department of Psychiatry, Division of Geriatric Psychiatry, Mount Sinai Beth Israel, New York, NY; and Dr. Lantz is Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY.

With the growth of the elderly population has come increased pressure on psychiatrists to offer timely access to quality care that is specific to the needs of the elderly, particularly the recognition of cognitive loss and dementia. Up to 40% of patients with moderate degrees of cognitive impairment remain unrecognized and undiagnosed by physicians.

 It has been postulated that some clinicians simply believe early detection does not change the trajectory of illness; some may feel that the tests are too time consuming or difficult to administer; still others may assume that their patients will resist the testing, without attempting to suggest it to their patients. However, the benefits of early detection of cognitive loss include counseling patients and their families regarding advanced care planning, preparation for financial needs, treatment of comorbid medical conditions, and maximizing functional status to promote better quality of life.

Cognitive impairment is not always associated with dementia. For this reason, a full comprehensive history is an integral component of any cognitive assessment. Presenting complaints of memory loss or changes in behavior, demeanor, or activity in the elderly population may be reflective of a psychiatric illness including a mood or anxiety disorder, a response to a new medication or a change of dosing, or an underlying medical condition. In some cases, what may appear to be a cognitive impairment may actually be an underlying depression or anxiety disorder in which attention and concentration become difficult. The following Case Vignette illustrates how complex presenting memory loss can be when complicated by both medical and psychiatric comorbidities.

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Mr. B is a 76-year-old man with multiple medical problems including diabetes mellitus, hypertension, hyperlipidemia, glaucoma, and obstructive sleep apnea. He is referred by his primary care physician (PCP) because of a decline in cognition over the past 6 months; his Mini Mental State Examination (MMSE) score decreased from 23 to 15. On interview, Mr. B appears tired and complains of poor sleep with frequent awakening during the night. He explains that he has difficulty filling his prescriptions and has not been taking his medications for many months. He also does not regularly use his continuous positive airway pressure device.

Mr. B describes feeling overwhelmed by his medical problems and depressed by his financial state. He is referred back to his PCP for care, given a referral for homecare services, and seen for follow-up. After 3 months of better adherence to his medical regimen, his MMSE score is 20/30. He remains depressed and is treated with sertraline, with follow-up visits at regular intervals that his daughter takes him to.

Complex medical and psychiatric comorbidities need to be identified as part of the cognitive screening examination in order to create an appropriate treatment plan. It is important to consider and rule out metabolic, vascular, and endocrine illness and to consider causes of acute confusional states. Often, identifying and appropriately treating a medical disturbance can improve or restore the level of cognitive function. Cognitive impairment may relate to language, executive functioning, social cognition, perceptual/motor functioning, or complex attention (

A picture of the patient’s functional capacity should be obtained, including ability to perform basic activities of daily living (washing, dressing, grooming) and instrumental activities of daily living including managing finances, shopping, transportation, telephone use, and medication management. Cognitive reserve factors should be well understood including the patient’s level of education, engagement in social and physical activities, and background of performing complex mental tasks.

The remainder of the assessment should focus on gathering a medical history, family history, substance use history, and medication review. Laboratory tests such as a complete blood cell count, electrolyte panel, renal and liver function tests, thyroid function, and serum vitamin B12 levels should be done to rule out any reversible causes of cognitive impairment.

The first step in integrating cognitive screening tools into practice is knowing who to screen and when to perform the evaluation. Generally, it is recommended that clinicians screen individuals with cognitive complaints, those with family who express concern about memory loss, and patients with multiple risk factors or advanced age.

There is no tool that is diagnostic for dementia. The current tools are screening measures, ie, they are designed to identify people who are at increased risk of disease. A number of cognitive screening tools have been developed, all exhibiting differences in their administration and scoring. They all share the goal of rapidly assessing cognitive functioning in the clinical setting.

The MMSE remains the most widely used tool as well as the most studied. The tool was compiled from a number of neuropsychological batteries and includes 5 for a possible 30 points2:

Limitations of the MMSE include poor sensitivity in frontal domains/executive functioning. In addition, patients with a higher degree of education or intelligence exhibit a ceiling effect.

The CDT has become popular with neurologists as well as psychiatrists because of its ease of administration, ease of scoring, and its capacity for testing multiple cognitive domains. The CDT screens through visuospatial, constructional praxis, and frontal/executive domains. The patient is asked to mark the time on a clock and is scored based on his or her ability to draw the circle, appropriately space the numbers on the face of the clock and, finally, for correctly representing the time. Strengths of this particular tool include the universality and cross-cultural ease with which representing time is understood.

 In comparison with other tools, there is less cultural bias involved and it also involves less bias due to intellect or education.

This is a 3-word recall test combined with the CDT. Again, it is considered relatively easy to use and fast to administer to the patient. Cognitive impairment is questioned when a patient is unable to recall any 1 of the 3 words listed with a normal clock, or if he or she is able to list 1 or 2 words but draws an abnormal clock. This screening test is thought to be useful in determining whether impairment is present; however, it is not useful in monitoring disease progression.

St. Louis University Mental Status (SLUMS)

Similar to the MMSE, SLUMS is a 30-point test that was designed to measure ability in the domains of orientation, executive function, memory, and attention. Some researchers argue that the SLUMS scale addresses some of the shortcomings of the MMSE, including being better at detecting aphasia as well as having less emphasis on orientation.

Some patients may self-refer for an evaluation of memory loss as illustrated in the following Case Vignette. These seniors may be worried by the thought of cognitive loss but have no signs or symptoms. This illustrates the reassuring nature of screening tests and the importance of repeating the screens at regular intervals.

Mrs. V is an 82-year-old widow who complains of feeling anxious and very worried about her memory. She has a friend who recently received a diagnosis of Alzheimer disease, and Mrs. V is fearful that she has this too. She does not describe any clear issues with her memory. She has no active medical problems, and her only medications are vitamin D and calcium. Mrs. V scores 30/30 on the MoCA, and her clock drawing is intact and accurate. She is mildly anxious but responds well to reassurance. She is given a referral to a local senior center that provides support and stimulation, including memory-enhancing programs. She is instructed to return in 6 months for clinical follow-up.

MoCA was developed to enable earlier detection of mild cognitive impairment than the MMSE. The score range is the same as the MMSE, but it involves additional tasks that are better able to screen for difficulties with executive functioning. The MoCA also addresses bias due to educational level by adding 1 point for individuals whose level of formal education is less than 12 years.

The AMT is a 10-item scale for screening cognitive impairment, including domains such as short- and long-term memory, attention, and orientation. A score of less than 8 suggests a cognitive impairment. The benefit of this scale is its rapid administration time (roughly 3 minutes); an even shorter 4-item scale is also available. It is favored in busy clinical settings or in emergency departments, where lengthy screening tools are difficult to use.

Cognitive screening tools have advantages and limitations (

). The MMSE can be difficult to administer to patients with sensory or communication disorders. The MoCA takes into account the patient’s education level; it can be slightly lengthier toadminister than the MMSE or Mini Cog. The clinician may also consider the use of specific tools that involve less cultural bias. The Rowland Universal Dementia Assessment Scale (RUDAS) is a 6-item screening tool developed to avoid items that may be subject to cultural or educational bias.

Health care practitioners should be mindful of cultural barriers in the use of cognitive tools. Psychiatric illnesses, including dementia, can be more difficult to detect in individuals who do not speak English as a primary language, or in those who are not familiar with Western cultural norms. Cultural competency issues may also include communication barriers, varying attitudes among cultures regarding dementia, and varying beliefs on what it is important to report to a clinician.

The authors report no conflicts of interest concerning the subject matter of this article.

Chodosh J, Petitti DB, Elliott M, et al. Physician recognition of cognitive impairment: evaluating the need for improvement. 

Sheehan B. Assessment scales in dementia. 

Shulman K. Clock-drawing: is it the ideal cognitive screening test? 

 Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder: a pilot study. 

 Woodford HJ, George J. Cognitive assessment in the elderly: a review of clinical methods. 

Storey JE, Rowland JT, Basic D. The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. 

• Geldmacher DS, Whitehouse PJ. Evaluation of dementia. N Engl J Med. 1996;5:330-335.

• Iracleous P, Xin Nie J, Tracey S, et al. Primary care physicians’ attitudes towards cognitive screening: findings from a national postal survey. Int J Geriatr Psychiatry. 2010;25:23-29.

• Jacinto AF, Nitrini R, Brucki SM. The pros and cons of early diagnosis of dementia. Br J Gen Pract. 2013;63:463.

• Leifer BP. Early diagnosis of Alzheimer disease: clinical and economic benefits. J Am Geriatr Soc. 2003;51:S281-S288.

• Panegyres PK, Berry R, Burchell J. Early dementia screening. Diagnostics (Basel). 2016;6:E6.

Articles

The cases presented here illustrate the complexities of memory loss and psychiatric comorbidities.

Tools and Tips for Assessing Cognition in Older Adults: Issues for Psychiatrists

Dr. Suryadevara is Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, FL, and Assistant Professor, North Florida/South Georgia VAMC, Psychiatry, Gainesville, FL. Dr. Holbert is Assistant Professor, Department of Psychiatry, University of Florida, and Dr. Averbuch is Associate Professor, Department of Psychiatry, University of Florida.

The United States is currently in the midst of an opioid epidemic. The numbers are staggering: in 2016 there were 78 deaths per day from drug overdose, two-thirds of which involved opioids. Since 1999, deaths from opioid prescriptions have more than quadrupled.

As is often the case, the origins of this epidemic are multifactorial. Some overprescribing can be traced back to the health care profession’s efforts to recognize pain as the fifth vital sign, which compelled physicians to treat more aggressively. Some pharmaceutical companies may have also contributed to the problem through aggressive marketing of prescription opioids without proper emphasis on their addictive potential. Regardless of the cause, the problem is pervasive, affecting all socioeconomic groups and spheres of society.

While opioid use disorders are more common in younger patients, prevalence among the elderly is growing, and misuse poses unique risks in the geriatric population. From 1996 through 2010, the number of opioid prescriptions provided to older patients increased 9-fold. More alarming, 35% of patients aged older than 50 years with chronic pain reported misuse of their opioid prescriptions in the past 30 days.

 The hospitalization rate for geriatric misuse of opioids has quintupled in the past 20 years alone.

 Given the scope of the problem, federal and state governments have begun to implement new guidelines in prescribing opioids, but tighter regulations may intrude on individualized patient care and the benefits of opioid therapy in some patients. Whether these new policies are the best strategies remains to be seen.

Avoidance of iatrogenic addictions may be the first step in addressing the epidemic. Some situations are more straightforward. Most clinicians can distinguish which of the following fictional cases is an inappropriate use of opioids: a 78-year-old in hospice care for terminal lung cancer; a 65-year-old who underwent major surgery that morning; or a 68-year-old with a history of depression, anxiety, and chronic pain, and a urine drug screen positive for cocaine, opioids, and benzodiazepines (prescribed). Contrast that with more complex, typical clinical scenarios in which the distinction can be a real challenge.

Mr. X is a 66-year-old under hospice care for hepatocellular carcinoma, with a comorbid severe alcohol use disorder. Opioids were prescribed until his urine drug screen came back positive for marijuana and cocaine. Two days after opioid therapy was stopped, the patient was found dead due to a self-inflicted gunshot wound. Pain was determined to be a major contributing factor. This case highlights the importance of understanding the delicate balance between risks and benefits when prescribing opioids, and the unique role psychiatrists play in their use.

Opioids reduce the perception of pain and produce a sense of well-being by binding to opioid receptors (mu, delta, and kappa) distributed in the brain, spinal cord, and other peripheral tissues. When deeper brain regions are stimulated by opioids, drowsiness and respiratory depression ensue. Opioids are classified by their origin, mechanism of action, or potency. Based on their origins in nature, opium, morphine, and codeine are opiates. Semi-synthetics include hydromorphone, hydrocodone, oxycodone, and heroin. Completely synthetic opioids are manmade and include fentanyl, methadone, pethidine, levorphanol, tramadol, and dextro­propoxyphene. Based on their potency, codeine, hydrocodone, and oxycodone are considered mild opioids; morphine, meperidine, hydromorphone, fentanyl, and methadone are classified as major opioids. All are opioid agonists with the exception of buprenorphine, which is a partial agonist/antagonist.

Opioids are generally used for acute and chronic pain, active-phase cancer treatment, palliative care, and end-of-life care. The latter situations are relatively straightforward as the benefits are uniformly perceived to outweigh the risks. Standards for treatment of acute pain are similarly uniform among most physicians, with only minor variations. For treatment of nonmalignant chronic pain, there is far less agreement among providers. There are no clear data to support the long-term effectiveness of opioids in these conditions. Hence, guidelines have been established on when to initiate or continue treatment, selection of the proper opioid, dosage, duration of use, and when to discontinue therapy. These guidelines also outline how to conduct a thorough risk assessment and address potential pitfalls.

Opioids are also used for non-medicinal, recreational purposes. In the elderly, the line between use for physical and psychological well-being is often blurred, which complicates attempts to determine prevalence. Numbers vary for different countries and are based on different study results, further confounding the data. This variation in prescribing patterns could be a result of the inconsistent practice styles among physicians and a failure to adhere to the guidelines that aim at standardizing practice. The changing demographics of the elderly American population further influence the prevalence of substance use disorders.

The decision to prescribe opioids in the elderly requires careful consideration of the many pharmacokinetic changes associated with aging. Age-related changes include a decrease in hepatic blood flow and volume along with decreases in renal blood flow and the glomerular filtration rate. Depending on the opioid used, it is essential to estimate the creatinine clearance and hepatic function for appropriate dosing adjustments. Other age-related changes that may influence opioid levels include decreased rates of absorption and increased adipose tissue. Many comorbid medical conditions seen in the elderly can lower the serum albumin concentration, thereby increasing the free opioid concentration.

Additional risks include the potential for serious drug-drug interactions with opioids. The likelihood of such interactions is directly proportional to the number of medications prescribed and compounds the risk of serious adverse events such as respiratory suppression.

Elderly patients often take a number of medications, and the combination of polypharmacy-related drug interactions, pharmacokinetic changes seen with aging, and multiple comorbidities can make pain management particularly challenging. The management of pain in the long-term care setting poses an additional set of challenges. According to the American Geriatric Society, nearly 80% of elderly patients in long-term care settings have substantial pain, yet 25% do not receive any treatment.

Patients at the highest risk for inadequate pain control include members of racial and ethnic minority groups, women, the elderly, those with cognitive impairment, and those with terminal cancer. Persistent and undertreated chronic pain can lead to a variety of negative psychosocial and clinical consequences, including limitations in daily functioning, disruption in workplace productivity, stress in interpersonal relationships, and worsening medical conditions.

Non-opioid pharmacotherapy and non-pharmacological therapy are the preferred modalities of treatment for chronic pain. However, in the proper contexts, opioids can be a useful treatment option. They are most beneficial in the short term for acute injuries, including the management of pain postoperatively. Use should be time-limited, except in managing certain cancer-related pain syndromes and as a part of end-of-life care. Particularly in the elderly, appropriate precautions must be taken.

Obtaining a thorough history is the first step. Screen for a history of opioid use disorder or other addictive disorders, including nicotine use disorder and any family history of addiction. A complete psychosocial history, including current stressors, history of childhood abuse or neglect, legal problems, and interpersonal relationship stressors will help to identify high-risk opioid misusers. Comorbid depression and high levels of pain are additional risk factors for misuse of opioids in the elderly. Always screen for cognitive deficits and other psychiatric disorders. Depression and anxiety may increase the perception of pain and require a different approach to pain management altogether.

Be alert for certain findings on the mental status exam such as confusion or any other indicators of a clouded sensorium, disheveled or unkempt appearance, thought content preoccupied with opioids, and dramatic or exaggerated pain-related behaviors suggestive of drug-seeking. While doing a chart review or using prescription monitoring programs, look for doctor shopping and requests for early refills. Other red flags include patients’ keeping only the appointments related to pain management, a history of positive urine drug screens or refusal of such monitoring, losing pain prescriptions, and having multiple providers prescribing the same or similar classes of medications.

After a complete history and examination, if the decision is made to begin opioid therapy, a detailed list of all medical conditions, allergies, and medications-including over-the-counter and herbal remedies-must be obtained and regularly updated. Drug selection should be based on careful consideration of potency needs and individual patient characteristics. Before initiating therapy, realistic treatment goals should be set after careful consideration of pertinent risks and benefits.

Begin with low doses and gradual titration, monitoring regularly for adverse effects and drug-drug interactions (Table). Common adverse effects include constipation, dry mouth, tolerance, dependence, nausea, vomiting, drowsiness, confusion, and low blood pressure. Warn patients about the risk of withdrawal with abrupt discontinuation. Serious adverse effects include respiratory depression leading to death, especially when mixed with benzodiazepines or alcohol. The use of benzodiazepines is contraindicated in patients who are receiving opioid therapy.

Combining analgesics with different mechanisms, together with nonpharmaceutical pain management strategies, may improve outcomes and minimize the need for opioid dose escalations. With multiple states enacting laws to legalize marijuana for medical conditions, marijuana may be one remedy for the opioid crisis. Some studies have shown that the hospitalization rates related to opioid abuse and overdose have decreased significantly in the states that offer medical marijuana. However, we should caution that the evidence is still preliminary and in need of further review. Moreover, the availability of multiple preparations and potencies makes uniform recommendations a particular challenge.

When opioids are deemed appropriate for the treatment of pain, monitor use carefully and be vigilant for patient misuse. State-sponsored, prescription drug monitoring programs may be an invaluable tool. Should signs of misuse, abuse, or diversion emerge, clinicians are encouraged to avoid outright dismissals from treatment, opting instead for referrals or in-patient treatment of substance use disorders. Patients should be given the opportunity to choose either medication-assisted treatment with buprenorphine or methadone maintenance or naltrexone. These treatments are often coupled with behavioral therapies to help with addiction.

Patients who are taking opiates should also continue to be monitored for drug-drug interactions, particularly with anti-epileptics, antidepressants, and other drugs metabolized primarily by the cytochrome P-450 system. Opiates are also notorious precipitating factors for delirium, but there is no clear evidence that the risk varies based on the type of opiate used.

 If an opioid regimen proves ineffective, clinicians may rotate the opioids or change the formulation based on consideration of pharmacokinetics and metabolism. Urine drug screens are routinely employed to check for the presence of other illicit or contraindicated substances and to investigate suspicions of drug diversion.

There is no evidence to support the long-term use of opioids for the treatment of chronic pain in the elderly. Rather, there is extensive literature that shows possible harm from long-term opioid use. For acute pain management, 3 days of opioid treatment is sufficient. In rare cases, this may be extended to 7 days. Immediate-release formulations are preferred over long-acting preparations. In cases of longer-term opioid therapy, clear and measurable treatment goals should be established and monitored regularly.

Assessments should focus on overall functioning and activities of daily living. Progress should be reevaluated no less frequently than every 3 months, with appropriate consideration for the taper or discontinuation of therapy, particularly in the absence of clinically meaningful improvement. We cannot overemphasize that, particularly in the elderly, opioids are far more effective when accompanied by a comprehensive and multidisciplinary approach using psychological support, physical therapy, and other complementary therapies.

There are legitimate uses for opioids in the treatment of a variety of pain conditions. However, the significant risks associated with opioid prescription must be carefully weighed against the potential benefits. The alarming rise in fatalities seen with the current opioid epidemic provides a vivid illustration of this challenge.

Our “textbook” and real-world cases illustrate the application of prescribing recommendations. Based on these principles, most clinicians would feel justified prescribing opioids for the cases of the 78-year-old in hospice care for terminal lung cancer as well as the 66-year-old in hospice care for hepatocellular carcinoma. However, in the latter case, the patient’s comorbid substance use disorder as well as the evidence of misuse on drug screening provides a more complex, real-world scenario. Such cases require difficult clinical decisions-sometimes with untoward outcomes. It is our hope that understanding the guidelines, following the standards of care, and documenting the same will help clinicians provide better care to complex elderly patients.

 Prevention, CDC Injury. (2016). Control: Prescription Drug Overdose. August 2017. 

https://www.cdc.gov/drugoverdose/epidemic/index.html

 West NA, Severtson SG, Green JL, Dart RC. Trends in abuse and misuse of prescription opioids among older adults. 

 Chang YP, Compton P. Opioid misuse/abuse and quality persistent pain management in older adults. 

 Owens PL, Barrett ML, Weiss AJ, et al. Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012. August 2014. 

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb177-Hospitalizations-for-Opioid-Overuse.jsp

 Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. 

 RodrÃ­guez MJ, de la Torre R, Ortega JL, et al. Evaluation of the quality of care of elderly patients with chronic and breakthrough pain treated with opioids: SAND study. 

 Guy GP Jr, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006-2015. 

Jones J, Sim TF, Hughes J. Pain assessment of elderly patients with cognitive impairment in the emergency department: implications for pain management: a narrative review of current practices. 

 Dubois MJ, Bergeron N, Dumont M, et al. Delirium in an intensive care unit: a study of risk factors. 

 Swart LM, van der Zanden V, Spies PE, et al. The comparative risk of delirium with different opioids: a systematic review. 

While opioid use disorders are more common in younger patients, prevalence among the elderly is growing.

Opioid Use in the Elderly

Dr. Lavretsky is Professor of Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles.

This Special Report on Geriatric Psychiatry addresses a variety of clinical issues in the rapidly growing diverse population of older adults. With the increase in the population of adults over age 65 years expected to reach 22% of the general population by 2040, neuropsychiatric disorders of aging will become a challenge for many practicing health care providers. This demographic trend has led to an intensive search for effective strategies to diagnose, treat, and prevent mental, cognitive, and physical disorders of aging.

The stigma of mental illness still overshadows proper diagnosis and management of neuropsychiatric symptoms and disorders in the elderly. The boundaries between neuropsychiatric and physical illnesses are often blurred, especially in the acute medical and in long-term care settings, because of frequently comorbid mood, anxiety, cognitive, and physical disorders in older adults. Aging-related physiological changes lead to the increased risk of adverse events such as falls and drug toxicity with pharmacological management.

The growing population of aging baby boomers brings to light new challenges characteristic of this cohort, such as increasing rates of drug abuse and higher rates of depression and anxiety, sleep disorders, and PTSD compared with previous generations. The issue of gender identity and the aging LGBTQ community is coming to the forefront of public and professional awareness of the unique health care needs of its members. It is also becoming more obvious that multiple diseases of aging share common risk factors and may benefit from shared treatment and preventive strategies, such as heart disease, diabetes, and Alzheimer disease.

The 7 articles in this section highlight common clinical dilemmas and outline the nuances of diagnosis, management, and outcomes-and provide helpful practical tips for clinicians. We hope that readers will find the information in this Special Report clinically relevant and helpful in the diagnosis and treatment of neuropsychiatric conditions in older adults.

Dr. Lavretsky reports that she has received research grants from Forest/Allergan.

This work was supported by the NIH grants MH97892, AT009198, and AT008383.

This Special Report on Geriatric Psychiatry addresses a variety of clinical issues in the rapidly growing diverse population of older adults.

Introduction: Neuropsychiatric Disorders of Aging

Dr. Wagner is Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX.

Recent studies have demonstrated the wide-reaching adverse effects of being bullied in childhood. These effects range from impaired academic performance to interest in cosmetic surgery.

 examined the relationship between bullying and academic performance. The study was made up of 965 third-grade children from public and private schools in Australia; 44.8% of the students were male. Bullying was assessed by child self-report on a bullying scale. The items on the scale included physical and verbal victimization. Reponses were yes or no; if yes, then information was obtained on the frequency of being bullied. Academic performance was assessed via a national achievement test that measured academic performance on 5 domains: reading, writing, numeracy, spelling, and grammar/punctuation.

Just over one-quarter (27%) of the girls and one-third (33%) of the boys reported being frequently bullied (defined as occurring once a week or on most days) during the past month. For boys, physical victimization was associated with lower numeracy scores compared with non-bullied peers. Boys who experienced both verbal and physical victimization had lower reading scores than boys who had not been victimized. For girls, verbal victimization was associated with lower writing and grammar/punctuation scores compared with those who were not bullied. Girls who experienced physical victimization had lower numeracy and writing scores. Girls who experienced both verbal and physical victimization had overall lower academic performance scores. In general, the academic delays were equivalent to approximately 6 to 9 months of learning for students who had experienced bullying compared with children who had not been bullied.

On the basis of these findings, the researchers recommend that prevention of bullying should be a major priority for primary schools. The findings suggest that teachers and parents should consider bullying as one possible explanation for their students performing below their academic expectation.

 examined the longitudinal association of bullying and substance abuse, as well as the role of depressive symptoms, in their study of 4297 5th-grade students. Students who completed baseline assessments and were evaluated in 7th and 10th grade were included in the study sample. Bullying (peer victimization) was assessed by use of a self-report questionnaire with items such as “How often do kids kick or push you in a mean way?” and “How often do kids tell nasty things about you to others?” in the past 12 months. Students were asked about their use of tobacco, alcohol, and marijuana in the past 30 days. Depressive symptom scores were obtained from items on a diagnostic interview depression subscale.

Students who reported being bullied frequently in 5th grade reported greater depressive symptoms in 7th grade. There was a positive correlation between 7th-grade depressive symptoms and 10th-grade alcohol use, marijuana use, and tobacco use. Overall, the experience of being bullied in 5th grade was associated with use of substances in 10th grade via the mediator of 7th-grade depressive symptoms. These findings were similar for girls and boys.

The results of this study demonstrate the lasting impact of bullying in elementary school into high school. Based on these findings, the researchers recommend that all youths be screened for bullying, depressive symptoms, and substance use.

 evaluated the association between bullying and access to a loaded gun without adult permission. Data were obtained from 10,704 students, aged 12 to 18 years, who completed the 2011 and 2013 School Crime Supplement (SCS) to the National Crime Victimization Survey. The SCS assessed school-based bullying during the current school year. Students reported whether they were bullied via traditional bullying (direct and indirect physical and verbal violence, social exclusion, and property damage) or cyberbullying (unsolicited sharing of private information online, social exclusion in electronic format, and threats or insults received via different cyber media). Access to a loaded gun without permission was obtained by self-report during the student’s current school year. Responses were yes, no, or don’t know to the following question: “Could you have gotten a loaded gun without adult permission either at or away from school?”

Access to a gun without adult permission was reported by 4.2% of the students. Students who experienced school-based bullying were 3 times more likely to report access to a loaded gun without adult permission than those students who are not bullied: 5.2% of those students who experienced traditional bullying; 9.2% of those who experienced cyberbullying; and 15.0% of those students who experienced both types of bullying reported access to a loaded gun without adult permission compared with 2.8% who experienced no bullying.

Given these findings, the researchers recommend that access to firearms be specifically addressed in evaluation of adolescents who report being bullied. This intervention may reduce the likelihood of self-inflicted injuries in adolescents who have been bullied.

 examined the association between bullying and interest in cosmetic surgery. Students from grades 7 through 11 were screened for bullying involvement (N = 2782). Bullying role (victim and/or perpetrator) was assessed by use of a self-report scale and peer nominations (adolescents identified other students who were perpetrators or victims of bullying). Psychological functioning was assessed using scales that measured self-esteem, body esteem, and emotional problems. Seven hundred fifty-two students (53.3% female) who screened positive for bullying involvement were assessed for their desire for cosmetic surgery. The evaluations were based on students’ responses to the following items:

1 “I would like to have cosmetic surgery so that others would find me more attractive.”

2 “I would consider having cosmetic surgery as a way to change my appearance so that I would feel better about myself.”

3 “If I was offered cosmetic surgery for free, I would consider changing a part of my appearance that I do not like.”

Responses to these items ranged from not at all to very much.

Bullying role and percentages were as follows: bully-victim (those who are bullied but also bully others; 39.1%); bully (19.5%); victim (18.2%; 67.6% of these were girls). Psychological functioning was significantly poorer for victims and bully-victims than for bullies and adolescents without a bullying role. Victims of bullying had the lowest self-esteem and lower body esteem than the other groups. Adolescents who had any role in bullying were significantly more interested in cosmetic surgery than adolescents uninvolved in bullying. The desire for cosmetic surgery was highest in victims and in girls compared with boys. Poor psychological functioning was associated with being bullied, which in turn led to increased desire for cosmetic surgery.

The researchers suggest that screening tools be used to assess bullying for individuals who seek cosmetic surgery. Treating the mental health impact of bullying may reduce the desire for cosmetic surgery and possibly unnecessary procedures.

 Mundy LK, Canterford L, Kosola S, et al. Peer victimization and academic performance in primary school children. 

 Earnshaw VA, Elliott MN, Reisner SL, et al. Peer victimization, depressive symptoms, and substance use: a longitudinal analysis. 

 Simckes M, Simonetti JA, Moreno MA, et al. Access to a loaded gun without adult permission and school-based bullying. 

 Lee K, Guy A, Dale J, Wolke D. Adolescent desire for cosmetic surgery: associations with bullying and psychological functioning. 

More Reasons to End Bullying

It is interesting that some of the thorniest ethical dilemmas in psychiatry evolve around food: 

 in anorexia nervosa, artificial nutrition and 

 at the end of life, and the subject of the 

-the covert administration of psychotropic medications.

Here is a brief recap of the case to reorient us before we turn to the quiz answers and commentary. Mr. B, an 85-year-old with vascular dementia, had been transferred to an acute geropsychiatric unit. Mr. B was admitted for psychiatric stabilization after he became aggressive toward residents at the dementia care facility where he has resided since his daughter, who is also his medical power of attorney, could no longer safely manage him.

Initially, the patient responded well to valproic acid and was about to be discharged back to the facility when he began to refuse the drug. His behavioral disturbances rapidly returned and required several emergency administrations of antipsychotics. When none of the environmental and behavioral techniques the team tried could persuade Mr. B to take the mood-stabilizing medication, the pharmacist suggested covert administration in applesauce. The treatment team was sharply divided on whether such 

 of the medication was ethical and requested an ethics consult to assist them.

Readers were asked to imagine they were the ethics consultation team leader and to work through a series of 4 questions about the case. There were some very perceptive comments online that I will try to incorporate into the commentary.

1. When reviewing the case summary the attending has prepared, the opinion of the psychologist seems most consistent with which major ethical theory?

Clinicians, including myself when I am not wearing my ethics hat, often think ethicists spend way too much energy on ethical theories that often seem the secular equivalent of analyzing how many angels can dance on the head of a pin. We should instead just get about the business of doing what is best for the patient. Yet determining what is best is often surprisingly difficult: ethical theory, like changing the lens in your glasses, can often help us see aspects of the ethical concern previously not appreciated, such as the view of the psychologist. The answers offer a mini-tour of ethical theory.

 For the consequentialist theories of which utilitarianism is the most well-recognized branch in health care, the outcome of an act or rule is determinative of what is best. In each situation, what is right or good is the action or decision bringing about the most happiness or health for the most people. Covert administration of valproic acid will quell the agitation that is keeping Mr. B from being discharged to his care facility, which is after all what his daughter and the treatment team both want to happen. This theory best characterizes the view of the psychiatric pharmacist.

 Deontologists often take positions diametrically opposed to utilitarianism, and that is the situation here. Deontology comes as close to endorsing absolute values as any theory. The psychologist, although he would likely not use the word, is a deontologist. The theory supports the psychologist in his moral claim that the duty to tell the truth outweighs any other ethical principle.

There is another layer though to the psychologist’s argument, and it is a bit of word play on “categorical.” Immanuel Kant, the founder of deontology, formulated the categorical imperative, one version of which is a philosophical restatement of the golden rule.

 Since no human being wishes to be lied to, the psychologist is arguing that Mr. B does not lose his human dignity when he receives a diagnosis of dementia.

 Aristotle’s virtue theory finds the good and right in the character and conduct of exemplary human beings. This is a favored theory among clinicians because we all can easily recognize a “good doctor or nurse.” Yet there are in our scenario no real obstinate villains but only uncertain heroes searching for the cleanest way to promote Mr. B’s welfare.

 Principlism would consider the big 4 ethical principles of autonomy, nonmaleficence, beneficence, and justice and through a process of weighing and specifying arrive at the optimal resolution of the dilemma. But such a process requires prioritization, and the nurses see not doing harm as most important, the pharmacist as doing good through managing the behavioral disturbances, and the psychologist as respecting the patient’s autonomy. So, while we have succeeded in identifying the salient values, we are no closer to knowing which one prevails in the case.

2. This question underscores the need to involve the daughter in the discussion and to clarify her authority to make the decision.

Those who commented on this question on the website hit the target when they asked, “Where is the daughter in all this, and what can she do?” To which the various answers explicated below offered answers.

 Before losing capacity, Mr. B named his daughter as what is technically called the health care agent (HCA) in his durable power of attorney for health care. This gives the daughter the legal right and responsibility to make the decisions about covert administration on behalf of her father in some states.

 This answer speaks deontological language: the daughter, even if she has the legal authority, does not have the moral authority to consent for a human being to be intentionally deceived.

 In many but not all jurisdictions, the daughter as in option A would have the authority to provide informed consent on her father’s behalf to the administration of covert medications. However, in some states, consent for psychotropic medications is reserved to a court-appointed conservator of treatment guardian or even the court itself. Dementia bedevils practitioners and courts alike as there is no judicial or clinical consensus on whether it is a psychiatric or a neurological, or a medical disorder.

 This is a variation on option C and would be true in a state where an HCA does not have the legal sanction to provide consent for psychotropic medication and conversely the court-appointed treatment guardian may not always be able to make medical decisions.

 The warrant for the judicial bifurcation is that psychiatric treatment requires a higher level of protection because of the vulnerability of the patient and the risks of the intervention, which is analogous to the more rigorous standard often required in 

3. Those experts who contend that surreptitious administration can be an ethical option specify conditions that must be met for the practice to be justified.

Question 3 assumes the daughter is empowered to provide informed consent for surreptitious medication and asks what ethical qualifications the consultant should stipulate. The answers were phrased in the negative, so readers were asked to pick which of the 4 listed choices should not be included.

 As with any treatment, the decision to administer the medication covertly should not be open-ended or unsupervised. The rights and welfare of the patient require that effectiveness of valproic acid in reducing the behavioral disturbances as well as any serious adverse effects such as thrombocytopenia or distressing symptoms such as gastrointestinal distress be monitored. Both the adverse and the positive effects may well alter the risk to benefit balance that underlies the ethical acceptability of the practice.

 While-depending on hospital policy-signature informed consent may or may not be required, a written treatment agreement protects all involved by ensuring the entire team has reached consensus about this unusual means of medicating Mr. B and that the daughter as HCA is informed of and concurs with the treatment plan.

 A formal treatment plan also is a safeguard against covert administration being a treatment of convenience. The staff should continue to try to persuade Mr. B to take the mood stabilizer and continue to find any other non-pharmacological interventions that can help manage his behavior.

 This answer describes what ethicists call a “right of conscience” or “conscience clause.” Staff who from a virtue or deontological perspective truly believe it is wrong to deceive any patient, even an incapable one, should probably be excused from the care of Mr. B out of respect for their moral beliefs. However, this recusal depends on hospital policy, ethical codes, and the pragmatic consideration of staffing.

4. This question comes back to the ethics consultant who having heard the ethical concerns of all the stakeholders must now make a recommendation. As a prelude to this, he considers the arguments and counter-arguments. Question 4 asks readers to identify the strongest of the latter.

 There is a consensus in law and ethics that in a true emergency that endangers a patient, other patients, or staff, psychotropic medication can be administered over the objections of a patient.

 The risk of course is that staff out of fear, burnout, or convenience will “find” or worse “provoke” the emergency. For this reason, many states require the permission of the court to administer antipsychotic medication on any regular basis against the will of the patient or his or her ethically appropriate decision maker. The nurses also have a humanistic point that holding Mr. B down and jabbing a needle in his arm is more painful and degrading than is sprinkling medication on his pudding.

 While beleaguered staff in taxing situations acting out of soft paternalism often question the motives of family members, there is no evidence in the case scenario that the daughter wants anything other than her father’s well-being. She refuses to consent to antipsychotics. As one astute reader pointed out, 

 is not a benign drug and for real informed consent this would need to be stressed.

Argument C is one of the strongest arguments in favor of covert administration of medication, as it has a track record of getting Mr. B back to the neuropsychiatric baseline where he can return to live in his nursing facility. The caveat being, as readers stated, that he may be given even more psychotropics in that setting without any of the due process protections the ward is utilizing.

 This option takes the long and most deontological and virtue theory view of the decision. Despite his dementia, Mr. B may well grasp that he is being “fooled” and become even more resistant to treatment and, more importantly, distrustful of not just the staff, but of his daughter when a nursing assistant, as frequently happens, tells him that his daughter consented to the deception.

When I was in training, one of my teachers told me, “We will all end up being geriatric psychiatrists,” and he was prescient. As the population, including us clinicians, ages-and sans the miracle cure or preventive for dementia we all hope to see-dilemmas like this one will increasingly be encountered, which is one reason ethical theory will always have a place in ethical deliberations.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM.

Forced treatment of anorexic patients: part 2

Determining the decision-making capacity of a patient who refused food and water

The noncompliant patient in psychiatry: the case for and against covert/surreptitious medication

Covert medications: act of compassion or conspiracy of silence

 Kant I. Groundwork of the metaphysics of morals. In: Gregory M, ed. 

Cambridge Texts in the History of Philosophy

. Cambridge, UK: Cambridge University Press; 1998.

Consent to Treatment of Adult Clients, 43 Mental Health, §1-15, 2006.

Psychiatric research ethics: an overview of evolving guidelines and current ethical dilemmas in the study of mental illness

 Appelbaum PS, Gutheil TG. Legal issues in emergency psychiatry. In: Appelbaum PS, Gutheil TG, eds. 

Clinical Handbook of Psychiatry & the Law

. 4th ed. Philadelphia, PA: Lippincott, Williams & WIlkins; 2007.

 Tariot PN, Schneider LS, Cummings J, et al. 

Chronic divalproex sodium to attenuate agitation and clinical progression of Alzheimer disease

Some of the thorniest ethical dilemmas in psychiatry evolve around food: forced feeding in anorexia nervosa, artificial nutrition and hydration at the end of life, and the covert administration of psychotropic medications

Food for Thought 

in criminal court, me in a flat-screen cell,

Dr. Berlin is Senior Affiliate in Psychiatry at the University of Massachusetts Medical School. E-mail: Richard.Berlin@gmail.com. His most recent collection of poetry, PRACTICE, is published by Brick Road Poetry Press.

Funny how fast we become prisoners with lost convictions as we fill out the forms, patients getting sicker while they wait.

Prior Auths

Remember the tag line for the ad for the 1975 movie 

? “Just when you thought it was safe to go back in the water.” Well, just when you thought you had about all you could stand to be mad about, those sharks at the insurance companies-duh, duh, duh, duh (

 shark theme music)-are back. Or more specifically, they never left.

What I’m referring to are the findings in the 

 released just after Thanksgiving regarding the status of mental health parity. I thought this was really bad timing, since most everyone was in a tryptophan-induced daze.

The title of the November 20, 2017 press release announcing the publication says it all: “Analysis Uncovers Significant Inequalities Between Mental and Physical Health: Lower Payments to Providers and Wide Disparities in Access to Benefits.”

 In case that wasn’t clear enough, the subheading is: “Data Points to Potential Violations of Mental Health Parity Laws: Shows Higher Out-of-Pocket Cost for Consumers When Compared to Physical Health.” Paul Wellstone and Pete Domenici, the 2 senators for whom the 2008 Mental Health Parity Act is named, must be turning over in their graves.

"If nearly 300 people dying each day from overdoses and suicides isn’t sufficient to motivate insurers to take immediate action to improve access to the full range of in-network benefits, we have a real problem-and it’s time to start holding them publicly accountable."

 was commissioned by the Mental Health Treatment and Research Institute, LLC, a non-profit subsidiary of the Bowman Family Foundation, and was released by a wide-ranging coalition of mental health and substance abuse advocacy groups, including Mental Health America, National Alliance on Mental Illness, American Foundation for Suicide Prevention, the National Association of Psychiatric Health Systems, and the American Psychiatric Association.

Milliman, a well-respected national actuarial and research firm, drew on 3 years of claims data, from 2013 through 2015, which encompassed information from their databases from over 40 million people and covered the usual array of hospital and ambulatory services in every state. Here’s what they found:

When taken together, the analysis paints a stark picture of restricted access to affordable and much-needed addiction and mental health care in an era of escalating suicide rates and opioid overdose deaths. Further, these disparities point to potential violations of federal and state parity laws, which require insurance companies to treat diseases of the brain, . . . the same way they treat illnesses of the body. . . .”

Patrick Kennedy, in a remarkable display of understatement, is quoted as saying, “If nearly 300 people dying each day from overdoses and suicides isn’t sufficient to motivate insurers to take immediate action to improve access to the full range of in-network benefits, we have a real problem-and it’s time to start holding them publicly accountable.”

Those of us who have worked in multidisciplinary practice groups will have long been aware of the low reimbursement psychiatrists receive compared with other medical specialties for the same services, such as for those billed under E&M codes. In case you thought maybe you were just unlucky to be working in a bad system that had poorly negotiated the contract with insurers, the Milliman report found this is a ubiquitous situation.

We all know, it’s one of the major reasons so many psychiatrists refuse to take insurance reimbursement. The approximately 20% average payment differential for the same billed code (in a large number of states they found the differential was 2- to 3-fold) is clearly a significant factor in the report’s finding that many more patients nationally use out-of-network mental health services than is the case for physical health.

The percent of outpatient mental health facility visits in 2015 which were out of network nationally was over 31% compared with only 5.5% for medical or surgical visits. This disparity was also found in mental health office visits, with almost 19% out of network for mental health visits compared with only 3.7% for physical health. Hospital care is even worse. In states representing about 30% of the nation’s population, out-of-network inpatient care was between 800% and 1000% higher than for medical care. And, nearly half the states, including my own, had reimbursement disparities as high as 30% to 69%.

Even though this report is damning to the insurance industry, the action steps are way too mild. They call on federal regulators to issue more specific guidance and immediately start audits of major insurers. That’s really going to happen with the current administration. They also call on companies and state agencies to conduct regular audits of parity compliance. Do they actually think that corporate contract negotiators don’t know what’s in the contracts? Are they kidding? For a number of years, I was involved in such negotiations regarding our medical school unified practice group, and those differentials were completely obvious. Anyone relying on other specialties to advocate for higher reimbursement for mental health in an environment where the contract total cost is a zero-sum game knows that it’s not going to happen.

What I think we need is a major class action suit in federal court. All the data from the Milliman report are already published, and the strength of such a case is crystal clear. Have a look at the full report

 and you’ll know such a suit would be on solid ground.

If the insurance companies haven’t complied with the legislation so far, which is obvious in the Milliman analysis, it’s not because they don’t know what the law requires. It’s just that they think they can get away with ignoring it, and they’ve been right so far. So what are we waiting for?

 American Psychiatric Association. News release; November 30, 2017. 

https://www.psychiatry.org/newsroom/news-releases/analysis-uncovers-significant-inequalities-between-mental-and-physical-health-lower-payments-to-providers-and-wide-disparities-in-access-to-benefit

 Melek SP, Perlman D, Davenport S. Addiction and mental health vs physical health: analyzing disparities in network use and provider reimbursement rates. Milliman Research Report. November 2017. 

http://www.milliman.com/uploadedFiles/insight/2017/NQTLDisparityAnalysis.pdf

If nearly 300 people dying each day from overdoses and suicides isn’t sufficient to motivate insurers to take immediate action to improve access to the full range of in-network benefits, we have a real problem.

Parity? Let Them Pay Out of Pocket!

Glaucoma represents the leading cause of blindness in the US and affects about 2.7 million Americans, according to the CDC. While glaucoma can develop in anyone, African Americans, people with diabetes, those with a family history of glaucoma, and people over age 60 are at increased risk.

About 44% of patients with glaucoma are treated with timolol eye drops, a beta-blocker that is systemically absorbed and may cause psychiatric adverse effects. Elderly white women with underlying cognitive impairment may be at risk for visual hallucinations related to the use of timolol eye drops for glaucoma, according to a 

“This case series highlights an important, although rare, adverse effect of this medication that clinicians should be aware of, especially when using it in elderly patients who may have coexisting CNS pathology. It is important that this adverse effect be recognized and appropriately managed to prevent otherwise unnecessary investigations and treatment,” wrote first author Tavish Nanda, MD, of Columbia College of Physicians and colleagues.

Clinicians should be aware of recent research that highlights an important, although rare, adverse effect of this medication used to treat glaucoma.

Vol 35 No 1