Every summer, we ask community providers who’ve consulted the PCL over the past year to share with us their feedback and improvement ideas. In 2024, we received survey responses from providers in 25 of the 35 Washington counties who consulted the PCL during this time. THANK YOU ALL for your time and thoughtful feedback.
Of those who responded to the survey,
98% were satisfied or very satisfied with the information and recommendations they received
99% were satisfied or very satisfied with the time it took to connect to the PCL psychiatrist
More than 91% indicated the consultation helped them care for a specific patient
89% said it would help in the care of future patients
95% of respondents said they would use the PCL again and would recommend the service to others
PCL Improvement Ideas
Can the PCL have psychiatrists available on evenings and weekends?
Good news! The PCL is available 24 hours/day, 7 days/week to prescribing providers so call us anytime you need a consultation.
It would be great if the PCL psychiatrists could help with legal questions.
PCL psychiatrists are clinical consultants, and legal advice is specifically outside the scope of the program, unfortunately.
Can the PCL psychiatrists come to our county and offer trainings?
If we had the bandwidth to do this statewide, we would! Instead, we share educational resources on our website and in every PCL newsletter, PCL News. Click this link to view previous editions: pcl.psychiatry.uw.edu/newsletter
During the COVID-19 pandemic, rates of posttraumatic stress disorder (PTSD) surged in the US. The Centers for Disease Control (CDC) and National Center for PTSD estimate that 5% of adults struggle with PTSD. Over the past five years, rates of PTSD in college students more than doubled. Globally, the World Health Organization (WHO) has found that 1 in 3 people who encounter trauma will go on to develop PTSD. And of those impacted, more than a quarter will experience severe symptomatology. 1,2,3
First recognized as “shell shock” in veterans returning from the Great War, our understanding of the brain and body’s response to trauma has evolved with time. As has our definition of trauma. PTSD is characterized by the following constellation of symptoms:
Avoidance (of places or stimuli that recall the trauma)
Negative alterations in cognition and mood
Markedly increased arousal and reactivity (sleep disturbance, hypervigilance, irritability)
These symptoms must come in the context of direct experience of trauma or extreme exposure to details of a trauma. Our definition of traumatic events and exposures include the classic exposures like war and violent crime but also now include motor vehicle accidents, extreme weather events, intimate partner violence and ACEs – adverse childhood events. We also recognize that sentinel events can precipitate PTSD as frequently as chronic exposure and serial events can. Our evolving understanding of trauma response has also broadened our diagnostic conceptualization. The WHO has recognized cPTSD or complex PTSD as being on a spectrum with PTSD and borderline personality disorder. That is to say, those who experience trauma may exhibit maladaptive coping strategies and interpersonal struggles alongside hypervigilance, re-experiencing and avoidance.
CLINICAL PRESENTATION
Patients with posttraumatic stress disorder frequently present to their primary care or family medicine providers before ever being seen by a psychiatrist or other mental health specialist. Those with PTSD frequently experience somatic complaints:
Headache
Constipation or Diarrhea
Insomnia
Changes in Functional Status
Without clear evidence of physiologic changes on exam, many patients leave appointments with unresolved worry, often returning to urgent care or even emergency department settings with similar complaints. Unfortunately, this often leads to a pattern of high utilization of services by patients and compassion fatigue and demoralization for healthcare providers.
When patients report recent or past exposure to trauma, obtaining a subjective history of symptoms alongside objective data is indicated. Many who suffer from PTSD will have co-occurring struggles with:
Substance Use
Depression
Anxiety and Agoraphobia
Executive Dysfunction or Functional Impairment
While it is often impossible to eliminate confounding variables, trauma and trauma response are often central to many other mental health struggles. And accurately diagnosing PTSD and steering patients towards effective and evidence-based treatments will lead to an overall improvement in functioning and a decrease in suffering.
PATHOPHYSIOLOGY
Traumatic events, whether sentinel or chronic and sequential, elicit a reflexive fear response in the body and brain. Better known as “Fight, Flight or Freeze”, our autonomic nervous system quickly responds to a perceived threat to maintain safety. For those who move on from a traumatic event to experience PTSD, their autonomic nervous system is primed to respond. That is, their brain’s fear circuitry is chronically active, always ready to fight, flee (or freeze) if cues in the environment signal danger. While a car backfiring may elicit a startle response in the average person, those who struggle with PTSD would experience significant autonomic reactivity that may result in elevated blood pressure, heart rate and even panic. Signs of elevated autonomic arousal may include:
Elevated resting heartrate
Decreased heart rate variability
Elevated blood pressure
Decreased appetite and/or carbohydrate cravings
Impaired memory and attention
Insomnia
Fatigue
COLLABORATION AND CARE
Offering validation and acknowledgement of the severity of symptoms promotes trust with patients who have PTSD. A sturdy alliance with the promise of collaboration often leads to improved health outcomes and reduced utilization of services. Arriving at a formal diagnosis of PTSD is not always easy in primary care settings. The PCL website includes a link to the Primary Care PTSD Screen a 5-item screen designed to identify individuals with probable PTSD. Fortunately, formal diagnosis does not have to occur before symptom management can start.
Psychotherapy is the gold standard for treating PTSD. At the UW, we train providers in Cognitive Processing Therapy though we recognize this is a limited resource and there are other types of short-term, targeted therapy that patients may find helpful. Therefore, a referral to an experienced mental health professional is the preferred treatment approach. If a patient is struggling with co-occurring depression, substance use or severe functional impairments, consideration of involving Social Work would be indicated, as well.
Medication management of symptoms may include:
SSRIs to target anxiety and low mood
Prazosin to target nightmares and autonomic reactivity
AVOID benzodiazepines and hypnotics as these have been shown to worsen prognosis
Similarly, avoiding alcohol and other CNS depressants is advised
PTSD, like many chronic conditions, impacts entire family systems and the trajectory of many patients’ lives. Screening, diagnosis and intervention are essential so please never hesitate to seek out collaborative support from behavioral health providers including psychiatric consultation from the PCL team!
Dr. Burns is the medical director of UWMC-Roosevelt Outpatient Psychiatry Clinic. Her practice experience spans academic, research and clinical realms, with a focus on working with patients experiencing treatment-resistant depression, those with co-occurring medical complexities, and patients impacted by hormonal changes related to puberty, pregnancy, gender transitions and menopause. Dr. Burns’ background in the neurosciences and medical psychiatry gives her a comprehensive understanding of the biologic basis of psychiatric illness and the strength of the mind-body connection.
Related Resources
Dr. Burns presented on Navigating PTSD and Elizabeth Lehinger, PhD, presented on What is Complex PTSD? Understanding current evidence and treatment implications as part of the UW Psychiatry and Addictions Case Conference (PACC) series, a free, weekly teleconference that connects community providers from across Washington with UW Medicine psychiatrists, psychologists, and addictions experts. Sessions include both an educational presentation and (de-identified) clinical case presentations allowing providers an opportunity to receive feedback and recommendations from interdisciplinary attendees. CME is available for free or for a small fee. Visit the PACC website for more information.
The US Department of Veteran’s Affairs runs the National Center for PTSD, and their website includes a variety of free information and resources for patients, loved ones, and providers and has content in Spanish and English.
Depression is a prevalent and debilitating condition that affects millions of individuals across the United States. Primary care settings serve as the frontline for managing a broad spectrum of health problems, including mental disorders. Consequently, most patients receive treatment for depression directly from their primary care provider (PCP). Thus, PCPs play a crucial role in the initial identification, management, and follow-up of depressive disorders.
Most patients with depression can be effectively managed in these settings using evidence-based, first-line interventions like antidepressant medication and psychotherapy. However, some patients may not respond adequately to first-line treatments, necessitating consideration of alternative options. It is essential to recognize when to make this decision and to understand the array of possible interventions. This article describes neuromodulation co-management in primary care, in a manner similar to collaborative care, and specifically focuses on Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT). Guidance on referring patients to specialized care facilities is provided.
Neuromodulation
First-line treatments for depression typically include talk therapy like cognitive behavioral therapy (CBT) and antidepressant medications, such as serotonin reuptake inhibitors (SRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). While these treatments are generally well-tolerated and effective for many, approximately one-third of patients may not achieve sufficient symptom relief or may experience intolerable side effects limiting their usefulness. For these individuals, alternative approaches like neuromodulation may offer important benefits.
Neuromodulation is an emerging treatment area comprising various interventions that modulate neural activity in the brain to improve mood and other neuropsychiatric symptoms. These interventions are broadly categorized into invasive and non-invasive treatments, with most being low risk when used in the appropriately evaluated and medically optimized patient.
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation (TMS) involves delivering magnetic pulses to specific brain regions to modulate neural activity. This non-invasive procedure is brief (lasting about 20 minutes per session), performed on an outpatient basis, and is generally well-tolerated by patients. TMS is used adjunctively, meaning that patients often continue medications or talk therapy or both. Common side effects, such as headaches or scalp soreness, are relatively minor. The major risk is for seizure, which is mitigated through careful patient screening and strict adherence to treatment protocols.
TMS is FDA-approved for several indications, including Major Depressive Disorder (MDD), Treatment-Resistant Depression (TRD), Anxious Depression, Late-life Depression (up to age 86), Obsessive-Compulsive Disorder (OCD), and smoking cessation. TMS is covered by most insurance plans, although prior authorization is required, and not all indications may be covered. Importantly, TMS usually does not involve additional medical work-up for most patients. More information about TMS can be found here: https://www.uwmedicine.org/practitioner-resources/center-behavioral-health-learning/neuromodulation
TMS and Primary Care
PCPs can effectively co-manage patients undergoing TMS in collaboration with a CfN psychiatrist or other mental health specialist, if needed and similar to collaborative care. Established protocols for behavioral emergencies ensure outpatient safety, while adjunctive treatments, such as medications, may be recommended to optimize outcomes. Familiarity with combination antidepressant approaches is helpful for PCPs involved in co-managing these cases, especially when the acute series of TMS treatments is completed and the focus of care turns to relapse prevention.
Electroconvulsive Therapy
Electroconvulsive Therapy (ECT) involves administering electrical energy to the brain to stimulate neuroplastic processes resulting in modulation of neural activity. The procedure is done while the patient is under brief general anesthesia. ECT is a highly effective treatment for major depression, whether associated with unipolar or bipolar disorder or complicated by psychosis or catatonia, or when a rapid response is needed due to the severity of the psychiatric or medical condition. Most patients can receive ECT on an outpatient basis, though those with more severe depression may require inpatient management.
Although there are no absolute contraindications to ECT, there may be relative contraindications necessitating thorough evaluation and discussion to appropriately risk-stratify and medically optimize the patient. Insurance, including Medicare and Medicaid, generally covers ECT, though managed care plans will often require prior approval.
ECT and Primary Care
Patients undergoing ECT usually require co-management with a psychiatrist or other behavioral health specialist due to the severity of their illness, not because of ECT. The main role of the PCP in the patient undergoing ECT involves conducting a pre-operative evaluation for the procedure since brief general anesthesia will be used. After the initial phase of ECT, the focus shifts to relapse prevention over the following 6-12 months. Strategies for relapse prevention may include combination pharmacotherapy, continued ECT but at reduced frequency, psychotherapy, or other neuromodulation techniques. PCPs should be comfortable collaborating with behavioral health specialists during this phase to identify early relapse.
Conclusion
Managing depression in primary care settings is both a challenging and rewarding endeavor. While many patients respond well to first-line treatments like CBT and antidepressant medications, a significant proportion may require other interventions. Neuromodulation therapies, such as TMS and ECT, offer alternatives for patients who do not respond adequately to initial treatments. By leveraging collaborative care models and co-managing with specialists, primary care providers can continue to help patients and improve outcomes. Referring patients for neuromodulation consultation ensures their patients receive the most appropriate and effective intervention, thereby improving their overall quality of life.
Referring to the UW Medicine Garvey Institute Center for Neuromodulation
The Garvey Institute Center for Neuromodulation at UWMC-Northwest provides a comprehensive suite of neuromodulation treatments within a collaborative care framework, ensuring patients receive holistic and coordinated care. When considering a referral for neuromodulation consultation, primary care providers can access information on the CfN website. The referral process entails providing a reason for referral (e.g., diagnosis), a clinical synopsis of the case, details of current treatments tried, and, if known, the requested intervention.
What to Expect from the Initial Consultation
Comprehensive Review: The initial consultation at CfN provides a thorough review of the patient’s current and relevant medical and psychiatric history and documents a comprehensive mental status and behavioral exam.
Identifying the Best Intervention: The CfN consultant will determine whether neuromodulation is indicated, and if so, the most appropriate neuromodulation intervention to address the patient’s diagnosis.
Explaining the Procedure: The specialist explains the chosen procedure in detail, ensuring the patient understands and consents to the proposed treatment.
Preparation Steps: The consultation includes outlining the necessary steps to prepare for the procedure.
Feedback to the Referring Clinician: Finally, the specialist provides detailed feedback to the referring clinician, including findings, preparation or treatment plans, and follow-up recommendations.
Dr. Espinoza is the medical director of the Garvey Institute Center for Neuromodulation located at the Center for Behavioral Health and Learning. He specializes in behavioral health, psychiatry, and geriatric psychiatry. He holds certifications in electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).
Related Resource
Dr. Espinoza put together this presentation about the Center for Neuromodulation where his team provides state of the art neuromodulation and interventional psychiatry treatments including: Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (rTMS and dTMS).
Do you have patients who are misusing opiates? Do you wonder if you can manage prescribing medications for opioid use disorder (MOUD) or have questions about what to prescribe? Drug overdose deaths in the United States are at an all-time high, with most caused by opioid use, namely fentanyl. The good news is that effective medication treatments for opioid use are available, and in case you didn’t know, Washington providers can call the Psychiatry Consultation Line at 877-927-7924 to consult with our psychiatrists about using these treatments with your adult patients.
It’s critical for more clinicians to explore whether they can prescribe MOUD; in 2019, only 18% of people with opioid use disorder (OUD) received MOUD in the prior year. What are the MOUD options for your patients living with OUD?
Methadone
The three FDA-approved MOUD options are methadone, buprenorphine and naltrexone. Methadone is a full mu-opioid agonist that has been exhaustively studied and shown to be safe and effective for patients with OUD, particularly when dosed above 60 mg per day. Because of the time involved in titration, achieving a dose of methadone that alleviates cravings and protects patients from overdose can take weeks. Despite the efficacy data, methadone is the most tightly regulated MOUD, and it is only accessible through DEA-approved treatment facilities. Many counties in Washington have no methadone clinics, leaving those with OUD only two MOUD options: naltrexone and buprenorphine.
Naltrexone
Naltrexone, particularly in the form of the 380 mg per month, long-acting injectable is another option for patients. As a full mu opioid blocker, initiation of naltrexone requires full withdrawal from opioids. Starting naltrexone prior to completion of opioid withdrawal can result in precipitated withdrawal. Many patients are unable to achieve full cessation and thus studies have shown higher dropout rates with naltrexone for OUD compared to buprenorphine.
Buprenorphine
Buprenorphine is the third FDA-approved MOUD with evidence similar to methadone in terms of treatment outcomes. In years past, prescribing buprenorphine required at least 8 hours of training and an x-waiver. As of January 2023, this requirement was dropped and anyone with a standard DEA registration number can prescribe buprenorphine. Unlike methadone, buprenorphine can be prescribed in an office-based setting, making it more accessible for patients.
As a partial agonist with a high binding affinity for the mu-opioid receptor, buprenorphine is a very safe option for OUD. Even at maximum doses, patients do not experience respiratory depression with the medication alone. Further, doses of buprenorphine, which protect patients from overdose, can be achieved quickly in one or two days. Given the pharmacologic properties of buprenorphine, patients must be in some degree of opioid withdrawal prior to initiating buprenorphine, as it can otherwise precipitate opioid withdrawal. Typically, it is recommended for patients to achieve a clinical opioid withdrawal scale (COWS) score of 8 or more prior to initiating buprenorphine. Though precipitated withdrawal is not necessarily dangerous, patients feel extremely uncomfortable and can have negative connotations with buprenorphine, reducing their likelihood of continuing the medication in the future.
Thankfully this outcome is a relatively rare occurrence. In one recent study less than 1% of patients experienced precipitated withdrawal when dosed with buprenorphine after achieving a COWS score greater than 8. Techniques for initiating buprenorphine varies significantly, ranging from “low dose induction,” the practice of giving small doses of buprenorphine with gradual increases over time to “standard induction,” giving 4 mg -12 mg of buprenorphine in the first day, to “high dose inductions” initiating higher doses of buprenorphine, 16 mg to 32 mg quickly following emergence of withdrawal symptoms.
Buprenorphine Treatment Guidelines
Regardless of the initiating dose, the goal of treatment is to achieve a dose of buprenorphine that eliminates opioid withdrawal, significantly reduces or eliminates craving to use opioids, and blocks the effects of illicit opioids to the degree that the patient has significantly reduced, or better yet, stopped use of illicit opioids all together. If patients have cravings to use, evidence of withdrawal from opioids, or continue using illicit opioids, increasing the dose of buprenorphine should be considered. The current maximum dose is 32mg daily.
Previous guidelines have suggested that doses of buprenorphine beyond 24 mg may not be necessary, but these recommendations were based primarily on data associated with patients using heroin. In the current era where the illicit opioid market is dominated by fentanyl, patients may well require higher doses of buprenorphine. Typically, buprenorphine has been dosed once daily, but for some, 2-4 doses spread throughout the day are preferred. Buprenorphine has multiple formulations for the treatment of OUD which include sublingual, buccal, implantable, and long-acting subcutaneous injectable versions.
There are no clear data on the length of time patients with OUD should remain on MOUD. However, after cessation of medications, rates of return to use of opioids is high, so most experts recommend ongoing maintenance therapy with buprenorphine or methadone. For more information on treatment of patients with MOUD, please see the resources below. And please call the PCL at 877-927-7924 if you are a Washington provider who would like to consult about your adult patients with mental health and/or substance use care needs.
Author
Jonathan Buchholz, MD Director, Addictions Psychiatry Fellowship; Medical Director of Inpatient Psychiatry, VA Puget Sound
Dr. Buchholz specializes in working with individuals experiencing co-occurring mental health and substance use disorders, a process that reminds him of the amazing resiliency that lies within us all.
Related Resources
Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl Provides practical clinical practice-based guidance, based on available research combined with emerging clinical experience, on the use of buprenorphine in the treatment of individuals using fentanyl and other highly potent synthetic opioids.
Linking People with Opioid Use Disorder to Medication Treatment This prevention resource presents strategies that can help state, local, and tribal leaders and healthcare professionals link persons living with OUD to evidence-based care. Strategies are based on the best available evidence.
Medications for Opioid Use Disorder The Executive Summary of this Treatment Improvement Protocol provides an overview on the use of the three Food and Drug Administration-approved medications used to treat opioid use disorder—methadone, naltrexone, and buprenorphine—and the other strategies and services needed to support recovery.
Providers Clinical Support System-Medications for Opioid Use Disorders A program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and created in response to the opioid overdose epidemic. PCSS-MOUD’s goal is to provide evidence-based practices to improve healthcare and outcomes in the prevention of those at risk and treatment for individuals with an opioid use disorder (OUD).
Psychiatric disorders are common during pregnancy and postpartum. For example, rates of perinatal depression and anxiety are 15-20%. Twenty percent of people with postpartum depression have a bipolar spectrum disorder. In addition, many people have pre-existing psychiatric conditions and are already taking psychotropic medications when they become, or are planning to become, pregnant. The overall goal of treatment during pregnancy is to use the lowest number and dosages of medications possible, while effectively treating the underlying psychiatric disorder(s).
Although the Perinatal PCL receives questions about diagnoses, non-medication treatments, and resources and referrals, many calls are about prescribing and the effects of medications during pregnancy and lactation. Here, we provide some general guidelines about prescribing during the perinatal period and some resources to find information about risks of specific medications.
What are some general guidelines about prescribing during the perinatal period?
1. Consider risks during pregnancy whenever prescribing medication for someone of childbearing potential. About 50% of pregnancies are unplanned. Considering, and informing people of childbearing potential about, risks of their medication(s) during pregnancy helps to maximize prescribing of safer medications and avoid patients’ suddenly discontinuing needed medication if they find out they are pregnant.
2. Make any medication changes before pregnancy if possible. This minimizes the number of exposures for the baby and maximizes stability for the parent. Changing a newer medication with less data regarding safety in pregnancy to an older medication with more safety data can be done before pregnancy, if desired. Making this change once the patient is already pregnant involves exposing the baby to two medications instead of one and potentially causing worsening of the parent’s psychiatric condition during pregnancy.
3. Ideally, the patient should be psychiatrically stable for at least 3 months before trying to conceive. Although this is not always possible, it decreases the risk of relapse and exposure of the baby to risks of untreated/undertreated psychiatric illness.
4. Avoid polypharmacy whenever possible. Prescribing the fewest medications possible to effectively treat the patient’s psychiatric disorder reduces exposures for the baby. Reviewing the need for each medication is especially important when someone is taking multiple medications and/or more than one medication in a class (e.g., two or more antidepressants, two or more antipsychotics, multiple antianxiety/hypnotic medications, etc.).
5. Avoid Depakote. Depakote (valproic acid) is a commonly prescribed mood stabilizer for patients with bipolar disorder. Depakote is a known teratogen (rate of malformations elevated in all dosage ranges and 25% at doses above 1450 mg/day) and is associated with significantly decreased IQ in children exposed in utero.
6. Optimize non-medication treatments. At all times, and especially during the perinatal period, we want to maximize the use of evidence-based non-medication treatments such as psychotherapy. Even if someone requires medication for effective treatment of their condition, non-medication treatments can help minimize numbers and dosages of medications and increase effectiveness of treatment.
7. Remember that an untreated/undertreated psychiatric disorder also poses risks to the parent and the baby. Untreated/undertreated psychiatric disorders pose significant risks for parents and babies. For example, perinatal depression is associated with higher rates of preterm birth, low birth weight, problems with attachment and bonding, and increased rates of psychiatric disorders in childhood and adolescence. For this reason, it is important to treat psychiatric disorders effectively during the perinatal period.
8. If you are thinking of stopping your patient’s psychotropic medications because they are pregnant, please call us first. Discontinuing medications abruptly can precipitate relapse (another exposure for the baby and risk for the parent). Also, stopping some medications can cause withdrawal symptoms that are potentially dangerous (e.g., benzodiazepines) or unpleasant (e.g., antidepressants). We would be happy to help you sort out which medications to discontinue and safe tapering schedules.
9. Prescribing during the perinatal period requires a risk-risk discussion. Informed consent during the perinatal period involves collaborating with the patient in discussing and weighing risks of medication for the fetus/baby, risks of the psychiatric disorder, and possible alternative treatments.
10. Use a patient-centered and team approach. In addition to collaborative decision-making with, and support of, the patient, this includes involving family members and communicating with other care providers. It is important to educate the partner and/or family members about the risks and benefits of treatment as well as warning symptoms of relapse. Communication with obstetric and pediatric providers minimizes the patient’s hearing conflicting opinions and being confused and concerned.
The Perinatal PCL is a free, state-funded, provider-to-provider consultation line like the Psychiatry Consultation Line (PCL) but focused on behavioral health disorders and symptoms during the perinatal period (pregnancy and the first 12 months postpartum). We are available at 877-725-4666 or by email at ppcl@uw.edu, weekdays 9-5. Like PCL, we also offer scheduled consultations.
Any healthcare provider in Washington State can call us with any behavioral health-related questions about a patient/client who is pregnant, planning pregnancy, postpartum, or who has pregnancy-related complications (e.g., infertility, pregnancy loss). Perinatal PCL is staffed by University of Washington perinatal psychiatrists, an addiction psychiatrist with expertise in the perinatal period, and our program coordinator, who is trained in social work. We offer psychiatric consultation and local perinatal mental health resources. For more information about Perinatal PCL, and to access our online Perinatal Mental Health Care Guide, please visit our website.
Author
Deb Cowley, MD Board-certified psychiatrist at UWMC-Roosevelt UW professor of Psychiatry and Behavioral Sciences Medical director, Perinatal PCL
Dr. Cowley has expertise evaluating and treating women who have mental health issues during pregnancy and postpartum, and throughout their life cycle, including premenstrual and menopause-related psychiatric symptoms. Her clinical interests include anxiety disorders, depressive disorders, obsessive compulsive and related disorders, panic disorder, postpartum depression, evidence-based medicine, maternal mental health and women’s health.
Related Resource
Management of Psychotropic Drugs During Pregnancy Psychiatric conditions (including substance misuse disorders) are serious, potentially life threatening illnesses that can be successfully treated by psychotropic drugs, even during pregnancy. This review presents an up to date and careful examination of the most rigorous scientific studies on the effects of psychotropic drugs in pregnancy.
Other Resources
InfantRisk for Healthcare Providers This collection of apps is for healthcare providers and parents about the safety of medications during pregnancy and breastfeeding.
LactMed This database of drugs and other chemicals provides information about the safety of exposure during breastfeeding.
Reprotox This database of medications highlights their effects during pregnancy, breastfeeding, and development. (Requires subscription.)
MotherToBaby These fact sheets are for parents regarding risks of drugs (including non-prescribed drugs) during pregnancy and breastfeeding.
Perinatal Support Washington This non-profit organization provides a warm line, support groups, peer support, resources, and therapy referrals to support emotional wellbeing for new parents.
Guidelines on suicide care from national organizations such as The Joint Commission provide recommendations on suicide risk assessment. Implementing these in health care settings rapidly leads to an array of administrative questions. Who should conduct the assessment? What is the optimal clinical tool? How often should the patient be assessed?
Because we work in complex systems, answers to these questions are necessary to support consistent care. Here, I hope to balance these administrative questions of who, what, and how with a focus on the therapeutic question of why to conduct a suicide risk assessment. If we have an outcome in mind of a range of options to support a patient at risk of suicide – i.e. the why of assessment – this will influence what information we want and how to obtain it – i.e. the what and how of assessment.
The Purpose of Suicide Risk Assessment
Suicide risk assessment is not known to predict suicide or to provide useful categories of low, moderate or high risk to guide clinical interventions. As such, national guidelines outside of the United States have recommended a shift from “risk assessment” to individualized “needs assessment” that works with patients to determine what is needed to maintain physical and psychological safety.
From this principle, I will offer a statement on the purpose of suicide risk assessment: The purpose of a suicide risk assessment is to gather information for shared decision-making in developing an individualized, dignifying and respectful plan to manage suicide risk. The management plan will include specific interventions drawn from four broad categories of intervention: facilitating connectedness, addressing mental health and substance use disorders, safety planning, and reducing access to lethal means. Below, I will expand on these categories.
Facilitating Connectedness
Facilitating connectedness refers to our efforts to promote connections and supports that direct the patient towards life. The suicidal state has been characterized as an experience of “mental pain or anguish and a total loss of self-respect.” When we facilitate connectedness, we try to convey a sense of belonging, value and hope to provide relief from these negative emotional and psychological states. During a suicide risk assessment, this means inviting the patient to “tell the story” of how the current crisis developed. Listening with open attention conveys messages that I’m here with you, you matter to me, and I have hope for you. As the patient talks, we will listen for opportunities to facilitate connectedness based on their background, circumstances, mental health symptoms, and existing strengths.
For example, the Trevor Project provides 24/7 crisis support for LGBTQ+ youth. For patients whose circumstances include actions that have damaged or destroyed relationships, a clinician’s compassionate engagement with devastating shame can represent a crucial inflection point that begins to restore dignity and hope. Patients with psychiatric symptoms might benefit from referrals for medication treatment and psychotherapy to decrease isolation and increase hope. Patients who prioritize spiritual coping can be engaged to explore how connections to internal images, metaphors and beliefs and external rituals and communities might support coping and a pathway towards recovery. Patients who refuse treatment remain candidates for connectedness-based interventions. For example, the caring letters intervention demonstrated that non-demanding caring contacts – simply conveying care and support without any expectations from the patient – reduced suicide deaths by approximately half among patients who declined treatment.
Addressing Mental Health and Substance Use Disorders
Some suicide decedents – though not all – have been found to have psychiatric or substance use disorders. Regardless of whether a patient meets criteria for a specific mental disorder, addressing psychiatric symptoms and substance use represents an important aspect of managing suicide risk. When present, anxiety, agitation, and insomnia might represent particular priorities. Addressing mental health conditions may have different benefits for suicide risk. For some patients, simply learning that they have a diagnosis with effective treatments available provides de-stigmatizing relief that counters isolation, worthlessness, and helplessness. Alternatively, effective control of severe psychiatric symptoms might provide stability to participate in psychotherapy to focus on suicide-related thoughts of despair and self-hate. For others, effective treatment of a mental disorder reduces the destructive, alienating effects that the symptoms may have had on relationships.
Existing treatment settings for substance use disorders can also be a place for patients to learn how to recognize and respond to suicide risk in themselves or peers, an online training for $100. During a suicide risk assessment, we will listen for the patient’s background to learn of any history of mental health treatment and for current psychiatric symptoms and/or substance use, as this information will help us discuss treatment options with the patient. Patients who refuse treatment for mental disorders remain candidates for interventions targeting ambivalence, such as motivational interviewing. For example, exploring the pros and cons of medication treatment with a patient with opioid use disorder would be considered an intervention for suicide risk by addressing an important risk factor for suicide.
Safety Planning
Safety planning refers to the process of collaborating with a patient to generate coping strategies for use during periods of elevated suicide risk. “Brand name” safety planning interventions include Crisis Response Planning and the Safety Planning Intervention. While these interventions result in a written document that details personal warning signs of a crisis and coping strategies, both of them hinge on an initial narrative interview during which the patient is invited to “tell the story” of a recent suicidal crisis. The clinician then reflects back what the patient has described, highlighting that suicidal crises are time-limited events with a beginning, middle and end. The crises include intoxicating, preoccupying thoughts of suicide, wrenching emotional states and urges to bring an end to suffering by ending one’s life. This shared understanding of the nature of suicidality forms the foundation of safety planning: Do you see how the risk goes up and then comes down? I want you to feel confident with choices and skills to survive those dark moments so that we’ll have time to work on the longer-term problems that have caused so much pain. During a suicide risk assessment, we will listen for specific crises and details of circumstances, thoughts, negative emotional states and actions. We will also listen for strengths and resources the patient has used to cope with crises. This information will help us discuss with a patient their personal warning signs of a crisis and potential coping strategies.
As described here, safety planning occurs as a collaborative process where the patient participates in self-recognition and self-management of suicide risk. For some patients, the extent of their suicidal preoccupation precludes the ability to maintain safety independently. For these patients, a higher level of care in an inpatient setting may be needed for external support. During a suicide risk assessment, we will listen for the patient’s level of suicidal intent and planning to inform whether the patient has the willingness and ability to self-manage suicide risk with safety planning. Patients who refuse collaborative safety planning remain candidates for receiving information about crisis resources and when to use these: These are two resources that can help when people feel overwhelmed and have thoughts of suicide. One is 988Suicide and Crisis Lifeline where you or a loved one can talk with a crisis counselor; the other is the Crisis Text Line where you can text with a crisis counselor.
Reducing Access to Lethal Means
The “means” for suicide refers to the tools, instruments or objects that can be used to inflict self-injury. When people at risk for suicide do not have ready access to lethal means for use in a suicide attempt, this allows time to pass for a crisis to resolve and for risk to decrease. In lethal means counseling, clinicians have collaborative discussions with patients to motivate actions that reduce access to lethal means: I’m glad we’re talking today, and I believe your life can get better. A concern I have is that it sounds like there are times when the suicidal thoughts are especially intense. During those times, if you have immediate access to [means] we might lose you before we have enough time to work on the problems in your life. Can we talk about some ways to reduce your access to [means] so that you can survive to see things improve?
For firearms, which are especially lethal when misused in suicidal behavior, culturally-aligned counseling optimally occurs in a dignifying and respectful manner that resonates with the patient’s values. In Washington, it is legal to transfer firearms out of the home temporarily to manage suicide risk. For medications, clinician-initiated changes may also play a role: reducing the dose or amount dispensed of medications, selecting medications with lower toxicity, or discontinuing medications. During a suicide risk assessment, we will listen for background information that might suggest knowledge of or familiarity with particular means, suicide methods the patient has considered, and access to lethal means. In Washington, patients who refuse collaborative efforts to reduce firearm access and who are judged to be at high risk of harming themselves and/or others may be candidates for an extreme risk protection order as a legal process to recover firearms and prevent firearm acquisition.
Returning to “What” and “How”
In the sections above, I have described ways to manage suicide risk and the information needed from a suicide risk assessment to tailor these interventions for an individual patient. To summarize, we will need information about the patient’s background, life stressors, psychiatric symptoms, substance use, suicidal ideation, suicidal behavior, strengths and resources. In the language of risk assessment, these represent demographic, situational, symptomatic and suicide-specific risk factors, and protective factors.
To obtain this information in a way that facilitates connectedness and builds the rationale for safety planning, we will use a narrative interviewing technique that invites the patient to “tell the story” of how the current crisis developed: I’ll want to hear more about the suicidal thoughts, but first would you tell me (briefly) the story of what has brought you to think about suicide? Often the patient’s initial description does not include all of the elements of suicidal ideation and behavior we need to guide decision-making for managing suicide risk. To address this, we “back fill” with a suicide-specific assessment that asks specific questions about suicidal ideation, method, intent, planning, and suicidal behavior: Thank you for talking to me about this. I’d like to ask some specific questions about the suicidal thoughts, if that’s alright? With this range of information, we can proceed with shared decision-making to discuss a plan for improving safety using interventions from the categories previously described.
I hope this post has helped to clarify the role of risk assessment in suicide care. For future training opportunities and information on suicide care, please visit the Center for Suicide Prevention and Recovery.
Author
Jeffrey C. Sung, M.D. Clinical Assistant Professor UW Department of Psychiatry and Behavioral Sciences
Dr. Sung earned his M.D. at Northwestern University in Chicago, Illinois. His clinical interests focus on psychotherapy. He has taught psychodynamic theory, suicide risk assessment and managing response to patient suicide. Dr. Sung is a board certified psychiatrist and provides training and consultation through Forefront Suicide Prevention and the Center for Suicide Prevention and Recovery.
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Caring Contacts Training This is a free one-hour, interactive, self-paced training course developed for medical professionals and client-facing staff in WA state, and open to everyone. It is designed to address the public health crisis of suicide and give providers and client-facing staff additional tools to prevent suicide.
Preventing Addiction Related Suicide (PARS) PARS is a prevention intervention provided to addiction treatment patients who are at higher risk of suicide. The PARS web training costs $100 and is an interactive psychoeducational suicide prevention program that was designed to be used within community addiction group therapy treatment by addiction specialists and counselors, like SUDPs in Washington.
Suicide Risk Assessment and Documentation UW Psychiatry and Addictions Case Conference series (UW PACC)* Presenters: Jeffrey Sung, MD and Amanda Focht, MD The objectives of this presentation are to: 1) distinguish categories of risk and protective factors for suicide; 2) identify categories of intervention for management of suicide risk; and 3) describe components of suicide risk assessment and management documentation.
*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.
The lifetime prevalence of obsessive-compulsive disorder (OCD) amongst adults in the United States is 2-3%. While most providers can list the most common symptoms of OCD, the diagnosis is rare enough that it may have been a while since you got an update on useful screening tools and treatment recommendations. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a good place to start, and you can find this document on the Resources section of our website. The Y-BOCS contains a list of symptoms that can be helpful for making the diagnosis, as well as a rating scale that can be used to track treatment efficacy.
There are a wide range of obsessions and compulsions that can be seen in OCD and thus the symptom checklist on the third page of the Y-BOCS document can be very helpful when trying to establish the diagnosis. Moreover, the rating scale on the first two pages not only helps with establishing the diagnosis but is also useful for tracking the improvement seen with treatment.
The first-line treatment for adults with OCD is cognitive behavioral therapy (CBT) with exposure and response prevention. When medication is added to CBT, the usual first choice is an SSRI. Though an 8-week trial of an SSRI is adequate for some behavioral health diagnoses, patients with OCD may see better results from SSRIs at 16 weeks. Moreover, some patients with OCD require SSRI dosing that is titrated up toward the higher end of the usual dosage spectrum. This might mean, for example, a final daily sertraline dose of 150-200mg, rather than 50-100mg, if the patient can tolerate the higher dose.
For patients who have not responded to one or two different SSRI trials, clomipramine is sometimes trialed. SSRIs and clomipramine are not used together since the combination increases the risk of serotonin syndrome. In terms of efficacy, some clomipramine studies suggest this medication is superior to SSRIs in OCD. However, clomipramine is a tricyclic antidepressant and thus has more side effects than SSRIs, with anticholinergic side effects especially intolerable for some patients. Tricyclics also have a higher risk of cardiac side effects, even at normal doses, and are more lethal on overdose than SSRIs.
Atypical antipsychotics have some data as an augmentation strategy for patients who have a partial response to SSRIs or clomipramine. Lamotrigine and topiramate have a small amount of data for augmentation in refractory cases, as well. Clonazepam and lorazepam, on the other hand, do not generally demonstrate efficacy in studies of augmentation or monotherapy for OCD.
If you are considering using a medication for OCD, please first review your own reference material for full details on indications, side effects, dosing, monitoring requirements, and drug interactions. For reference, we most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington providers at heal-wa.org/professions.
If you would like more information on the spectrum of medications for OCD, please call the Psychiatry Consultation Line (877-WA-PSYCH / 877-927-7924) and one of our psychiatrists would be happy to review the data with you.
Author
Ryan Kimmel, MD Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences Chief of Psychiatry, University of Washington Medical Center Medical Director, Psychiatry Consultation Line
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OCD: Diagnosis and Treatment UW Psychiatry and Addictions Case Conference series (UW PACC)* Presenter: Deborah Cowley, MD The objectives of this presentation are to: 1) review the diagnosis of OCD and related disorders; 2) discuss the epidemiology, differential diagnosis, and comorbidity; and 3) discuss treatment of OCD and related disorders.
*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.
When providers reach out to the PCL program with questions about antipsychotics, we often include a document that outlines a schedule for monitoring metabolic side effects in our write-ups. While we follow this monitoring schedule for all antipsychotics, there are certain second-generation antipsychotics that are more notorious than others.
Olanzapine and clozapine, for example, are associated with the most weight gain. On the other end of the spectrum, ziprasidone and aripiprazole are associated with the least. Beyond the long-term cardiovascular risks, tracking the metabolic syndrome is also important because patients are understandably reluctant to continue taking medications that cause weight gain.
While there have been studies to suggest that metformin may have a modest, short-term benefit for olanzapine-associated weight gain, there is also data that switching from olanzapine to aripiprazole or ziprasidone can result in the loss of some of the weight gained while on olanzapine. There is a risk of decompensation when switching from one antipsychotic to another and the decision to switch is thus ultimately based on a variety of patient-specific factors. There are not yet any published, placebo-controlled trials on the use of semaglutide or tirzepatide for antipsychotic-associated weight gain.
Antipsychotics can also cause glucose dysregulation and lipid disturbance. These abnormalities can arise even in patients who are not gaining weight, which is why we monitor fasting labs as a matter of course. For a useful way to visualize the spectrum of antipsychotics in terms of their metabolic side effects, I’d recommend looking at Figure 3 of Pillinger’s article on antipsycohtics in Lancet Psychiatry 2020; 7: 64-77. In this “heat map,” red are the worst offenders and yellow the least, though you can see that no antipsychotic is wholly innocent.
If you would like more information on the spectrum of antipsychotic side effects, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review the data with you.
Author
Ryan Kimmel, MD Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences Chief of Psychiatry, University of Washington Medical Center Medical Director, Psychiatry Consultation Line
Within the last few months, a generic formulation of Latuda (lurasidone) has become available. Should you consider prescribing it for adult Bipolar I Depression?
Previously, this medication cost >$1,200/month and was thus out of reach for most patients and/or required insurance pre-authorization. Now that the price of lurasidone has fallen dramatically, it is worth comparing this medication to quetiapine, which is also generic and also has an FDA indication for adult Bipolar I Depression.
There aren’t very many head-to-head trials, but in meta-analyses of monotherapy for adult Bipolar I Depression, both lurasidone and quetiapine appear to be efficacious. Several published treatment algorithms consider both medications to be first-line options as monotherapy for this indication. In other studies, lurasidone has demonstrated efficacy for adult Bipolar I Depression when used as an adjunct to lithium or divalproex and, indeed, Latuda garnered FDA-approval for adjunct use for this indication.
FDA package inserts are available on the FDA approved drugs site. Package inserts contain a lot of useful information and are likely underutilized in our era of quick, app-based, medication references. When comparing the data reported in the package inserts for lurasidone and quetiapine, lurasidone appears to have a lower incidence of the antipsychotic-associated metabolic syndrome (weight gain, new-onset diabetes, new-onset hyperlipidemia, etc.). Lurasidone, at least at low doses, is also felt to be less sedating than quetiapine. However, when compared to quetiapine, lurasidone appears to have a higher incidence of parkinsonism, akathisia, and other D2 blockade-mediated side effects. For more details on the side effects of these medications, including information on the Black Box warnings, QTc prolongation, monitoring of the metabolic syndrome, and other adverse effects, please refer to your own medication reference material or the free sites available via Heal WA.
Another important difference between lurasidone and quetiapine is that lurasidone needs to be taken with a >350 calorie meal. This dramatically increases the absorption of lurasidone. However, food insecurity is a problem experienced by many people in our society, and it is important to ask your patients if they have regular access to a >350 calorie dinner.
Lurasidone dosing is usually initiated at 20mg/day. Though the FDA max dose is 120mg/day, some studies of adult Bipolar I Depression suggest that high-end dosing does not necessarily increase efficacy but might increase the risk of side effects. The mean (SD) lurasidone dose was 64.1 (14.4) mg in a 24-week open label study authored by Ketter et al for the journal Depression and Anxiety. Thus, rather than automatically pushing the lurasidone dose to the top end, it could be useful to first give the patient a good trial in the middle of the dosing range.
If you would like more information on the treatment of adult Bipolar I Depression, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review the options with you.
Author
Ryan Kimmel, MD Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences Chief of Psychiatry, University of Washington Medical Center Medical Director, Psychiatry Consultation Line
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Bipolar Disorder — Screening and Diagnosing in Primary Care UW Psychiatry and Addictions Case Conference series (UW PACC)* Presenter: Joseph Cerimele, MD, MPH The objectives of this presentation are to describe1) the clinical epidemiology of individuals with bipolar disorder in primary care settings; 2) techniques to improve the recognition of bipolar disorder in primary care patients; and 3) clinical characteristics of patients with bipolar disorder in primary care.
*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.
When it comes to treating adults with bipolar disorder, gabapentin appears to be everything you’d want in a medication…except for efficacy.
Prescribers wish that gabapentin had utility in bipolar disorder because gabapentin isn’t a P450 substrate, is renally excreted, and is generic and thus relatively affordable. Unfortunately, gabapentin does not demonstrate efficacy in randomized trials for bipolar disorder and current treatment guidelines do not emphasize its use. Despite of the lack of evidence, reviews of gabapentin prescribing patterns in the United States show that this medication is still being used with alarming frequency for bipolar disorder.
There are now five medications with specific, FDA approval for acute bipolar depression. Moreover, there are at least a dozen medications with FDA approval for acute mania. Many of these options are available in generic formulations.
Instead of reaching for gabapentin as a potential intervention for bipolar disorder, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review treatment options that have better evidence.
You can also call the PCL for advice regarding differential diagnosis, non-pharmacologic interventions, and treatment monitoring. In complicated clinical scenarios, discussing a patient’s care with a colleague can help you formulate a more comprehensive treatment plan.
The PCL is a free resource for healthcare providers in Washington State to consult with a psychiatrist about their adult patients with mental health or substance use conditions. Learn more at pcl.psychiatry.uw.edu.
If you are considering using a medication for bipolar disorder, please first review your own reference material for full details on indications, side effects, dosing, monitoring requirements, and drug interactions. For reference, we most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington providers at heal-wa.org/professions.
Author
Ryan Kimmel, MD Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences Chief of Psychiatry, University of Washington Medical Center Medical Director, Psychiatry Consultation Line
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Managing Bipolar Depression in Primary Care UW Psychiatry and Addictions Case Conference series (UW PACC)* Presenter: John S. Kern, MD The objectives of this presentation are to 1) recognize the predominant role of depressive episodes in the morbidity associated with bipolar disorder; 2) summarize the outcomes of the SPIRIT study; and 3) apply an orderly approach to the care of bipolar depression.
*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.
