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An interesting instance where practice has not been particularly supported by evidence.
Hopefully this new paper by Essock et al. is just a beginning. When it comes to polypharmacy, Essock et al concludes that there is “some evidence support[ing] a combination of antipsychotics and antidepressants for negative symptoms and comorbid major depressive episodes”. And that is pretty much all there is.

In other words:

No clear evidence for piling antipsychotics on the top of each other, which is common practice, or even for mood stabilizer augmentation.

Now, the problem with schizophrenia is that for most of the cases that end up in our clinics or hospitals, more often than not, we are looking at some degree of partial response. In clinical parlor these are the so called “treatment-refractory cases”.

And labels do matter: as one might need to carefully re-think their whole treatment plan when the problem is partial response, while “creative approaches” (i.e. not evidence based) are acceptable if the problem is defined as treatment residence. In other words, when the treatment refractory/resistance territory is seen as the medical equivalent of the Far West, with uncontrolled pathology looming darkly over the patient’s and doctor’s heads, shooting from the hip might be seen as actually the right thing to do. However, in medicine cowboyish approaches are never the right thing to do.

Essock et al. take home point? Think twice about combining medications.  The benefits are unclear, while the compounded toxicity is certain!

Just another reminder that conservative medicine is better medicine.

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Anxiety is a common complaint in a psychiatrist’s office.

When that is the case one needs to first rule out medical causes, drugs of all kinds (illegal and prescribed all together), and of course Axis I culprits such as generalized anxiety disorder, panic disorder, OCD, etc. Cluster C comes next as avoidant, OCPD and dependent people tend to be quite anxious.

And then there is the special kind of anxiety, concern, worrying about real issues: external (finances, work or relationship related etc) or INTERNAL (not liking oneself because of laziness, a bad temper, impulsivity, etc.). This is perhaps a good kind of anxiety – as long as it doesn’t reach an overwhelming intensity – and as such it should be supported.

In fact, invariably, therapeutic interventions, when successful, come with a good deal of anxiety. Nothing wrong with it as such ego dystonic states of discomfort are great motivators for completing the work.

When “good” anxiety presents itself for evaluation it should be seen as a good prognostic sign and an ally that one should value and co-opt when designing an intervention strategy.

Avoid the common mistake of labeling all anxiety as “bad”. The result is an universal goal of zapping anxiety off whenever, wherever you see it.

Not good. When it comes to anxiety nuances matter.


1. Course: ADHD is chronic versus bipolar: episodic. Which also means that you should see ADHD signs during exam, while we might or might not see signs of bipolar on presentation.

2. Long time prognosis: ADHD might get better with time while bipolar tends to get worse with time.

3. Drugs of abuse: ADHD: “cocaine (in general uppers) slow me down”. Bipolar: “I use uppers when I am down, downers when I am hyper”.

4. Family history: bipolar patients have more of a loaded fam hx in terms of affective and psychotic disorders.

5. When in doubt, safety comes first: assume and treat as bipolar (i.e. mood stabilizer) as while this will help a bipolar patient; at the same time, it might not help it would also not harm an ADHD patient. Stimulant first when in doubt is a risky choice: while it would help an ADHD patient, it will also hurt a bipolar patient who will escalade straight into severe mania.


Dual diagnosis technically means that the patient has two independent, i.e.  a primary psych and a substance misuse diagnoses. Which implies that a substance induced diagnosis has been ruled out. Easier said than done.

Case scenario: Patient reports a long history of polysubstance abuse and an equally long history of major symptoms (e.g., psychotic sxs, affective sxs, severe anxiety etc.)

How do you tease out what came first and what causes what? Ask:

1. Is there any history of sobriety?

‘No”. Then, you should assume that’s likely substance induced until proven otherwise (SIUPO).

“Yes”, then ask:

2. What’s the longest time that you’ve been sober?

If longest sobriety is less than a month, again likely SIUPO.

“More than a month”, ask:

3. During that time did you continue to have sxs?

“No”, SIUPO for sure.

“Yes”. Ask: What sort of sxs, etc.?

You see how the balance starts tilting towards dual diagnosis.

How does it affect you?


Most trainees do at least a fair job in gathering a long list of past and present symptoms and signs of psychiatric and other medical syndromes.

Most trainees also almost always forget to ask this ONE question:

“And how does this affect you?” Where “this” can be depression, anxiety, you fill in the blanks…

What do you get for this one question?

1. Improvement of rapport. As this question is not only a data gathering tool but also shows being concerned and caring about the patient’s experience.

2. A preliminary estimate of the patient’s insight.

“It affects me in a good way. I kind of like it actually.” A manic response.

 “Well, it affects me all right. I would like to have them stop following me.” A psychotic response.

“It drives me nuts. I would like to stop it.” An ego-dystonic response of an OCD patient.

3. When the level of insight is good: An estimate of the level of dysfunction.

“I can still work but I really feel like I am dragging my feet every day.” For a depressed patient this is probably more than mild but less than severe depression.

“It’s more of a nuisance. I am noticing it,  maybe my wife, but no one else”. For a patient complaining of short term memory loss this is probably more than just plain age related memory loss, but less than full blown Alzheimer’s Dementia. Mild cognitive impairment is likely.


Look for:

1. Independent psychotic symptoms

2. Historical and quantitative predominance of affective symptoms: e.g. “for most of my life I’ve been depressed/hyper”; “yes, I do hear voices but my major problem is not the voices but my depression. That’s what always gets me hospitalized”.

3. Rapid decompensations and rapid response to meds. Schizophrenia tends to be fairly chronic. Even when it presents with more of an episodic course it is still typically slow to take off and then get under control.

Past Psychiatric History


There are many things you can ask but here is a minimalistic list of informative data:

1. How many visits to a psychiatric ER?

Too many to count“: usually indicates a severe Axis  I disorder (psychotic or affective), personality disorder, moderate (or more) panic disorder, somatization disorder, or secondary gain (which can also be part of a personality disorder). Very few or none (esp. in an older patient) usually rule out Axis II.

2. How many of the above (ER visits) were followed by hospitalization?

Most of them“. Balance tilts toward Axis I. Most of them were not: balance tilts toward Axis II.

3. How many psychiatric hospitalizations total?

Too many to count: reserved prognosis (due to chronicity, dual diagnosis or Axis II comorbidity). Consider non-compliance and dual diagnosis. Just a few/none: good prognosis.

4. What was the chief complaint/reason for most of the hospitalizations/ER visits?

Great screening question. Voices or paranoia versus depression with suicidal ideation will greatly focus further inquiry.

5. What was the longest hospitalization?

I started to appreciate this question after one patient told me his been hospitalized only twice before. I was puzzled and had a difficult time understanding the mismatch between his level of dysfunction (which was pretty significant) and the very low number of hospitalizations. It turned out that his second hospitalization was 12 years long, in one of the state forensic facilities. So, while the total number of hospitalizations is informative, what really matters (when it comes to prognosis and understanding dysfunction is the total duration of the time one spend inpatient).

6. What medication(s) worked the best/was the worst?

Good question to further narrow the differential. Also, it will save you time to cross off the list ineffective/poorly tolerated medications. Futher, usually there is no need to reinvent the wheel: if a specific intervention worked once, change is that it will work again (the exceptions here is a medication tachyphylaxis reaction, more commonly known as “poop out” phenomenon, where a medication that is effective stops working)

7. Is there a history of noncompliance? Why?

Two benefits: 1. Gives a good measure of the patient’s insight. 2. Places the patient on the stages of change continuum and thus allows you to tailor your intervention accordingly.

8. Were you using drugs around the times when you got hospitalized?

If the answer is”yes, time and again” you should re-asses what’s primary versus secondary.

9. Tell me what’s the most violent you’d ever been.

Open ended increases the chance to get a valid answer.

10.  Did you ever find yourself wishing to be dead?

Suicidality is a sensitive topic. Go straight for a past history of attempts you might put the patient off. Also, your range is too narrow. Start with a broad question and follow up with more specific questions (use a concentric approach) and you will get more honest and comprehensive (thus also more valid) answers.


A few nursing students followed me for rounds today.

It turned out that, as part of their rotation requirements, they are supposed to complete a psychiatric interview. As they never talked to a psychiatric patient before they wanted to know about the do’s and dont’s… After talking further it became clear that their image of a psychiatric patient was the too common stereotype of a highly volatile, potentially dangerous, explosive, out of control, unpredictable person.

Instead of answering their question I asked them what was the most striking and unexpected aspect of the rounds they just saw. “It was very casual”, they said. “The way you interacted  – it was all very “normal”.” “The patients knew about their symptoms and treatments.”

Yes, most of them do.

There are always “normal” and “healthy” parts of the self that survive even the most damaging mental and emotional storms. Your expertise is to find these islands, terra firma amidst on ocean of otherwise overwhelming feelings and thoughts. That is where you want to meet your patient. As that will be the safe harbor, the heaven from where you’ll journey together to chart and explore and bring “back to civilisation” the unruly oceans of raw experience.

When terra firma is where you will meet you only need to remember that you are nowtwo equally good beings: terra firma to terra firma, human being to human being. The only difference is that you are there to offer (not force) help, out of caring for the other.

Remember this: respectful offering of help – and you will have no troubles approaching any psychiatric patient. Or, even more, approaching anyone, anywhere, for that matter.


Common scenario:

Patient has been doing well on meds. All of a sudden no longer doing well.

What’s happening?

Hypothesis: The medication(s) stopped working.

Possible explanations:

1. Medication(s) all of a sudden became ineffective. What’s the chance of that? Small.

2. Patient stopped taking the medication(s) as prescribed. What’s the chance of that? High.

Solution: Make sure compliance is optimal BEFORE considering medication changes.

Stages of Change


I find Prochaska and Di Clemente’s model of change a very useful guide for my first encounter with a new patient.

We see people who have issues.

The important question is: on the change continuum, where does your patient place himself regarding his ability to engage in change work? A practical question as the answer will inform your intervention as much as current Axis I symptoms and personality dimensions.

Case and point:

Approaching an already committed to change patient with an educational agenda is poorly timed at best, and, at worst, unproductive and even irritating to the patient. It is an equal waste of time to approach a precontemplator with a list of change promoting interventions (which would be much better suited for patients already are in a preparation or action stage).

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