How to Use Smartphrases

How to Use Smartphrases in Psychiatry

What is a smartphrase?

A smartphrase is a way to tell the computer to replace a word with another word (or pages of words!).

Why use smartphrases?

Smartphrases are awesome because they save time, and make it easier to provide good documentation and care.

With smartphrases, we can create a library of phrases, paragraphs, or documents, and, then, with a couple of keystrokes, import it into the electronic medical record.

Here are some examples…

Prescribing and Informed Consent

Smartphrases are good for inserting (and remembering) the medication doses and schedules you’d like to prescribe.

We would type .rxTrazodoneInitial and get the following smartphrase:

Trazodone: Take 1/2 tablet (25 mg) to 1 tablet (50) at bedtime as neeed for sleep; okay to increase by 25 mg per night if ineffective and well-tolerated; do not exceed 200 mg dose; hold for excess sedation, cognitive impairment, orthostasis.

Then for documenting and guiding the informed consent process, we could type .icTrazodoneMale, and get...

.icTrazodoneMale
Informed consent disclosed for trazodone. Discussed excess sedation, orthostasis, cognitive impairment, priapism for trazodone. Discussed non-ahderence/abuse. Warned.

The text expander program, which you will learn how to use, has saved the information you want called up, and inserts it for you, when you type the smartphrase.

Making Note Writing Easier and Faster

Smartphrases are good for creating, borrowing, and storing parts of the note that you use frequently, such as intake notes, screening measures, mental status exams, and diagnostic criteria.

We could type the following smart phrase:

.dxADHD

And the following text would autoinsert in the note:

“The patient currently endorses or denies the following features of ADHD based DSM-5:

INATTENTIVE SYMPTOMS (Need 5 or more symptoms for Inattentive Type)
Fails to give close attention to details Y/N
Difficulty sustaining attention Y/N
Does not seem to listen Y/N
Does not follow through easily side tracked Y/N
Has difficulty organizing Y/N
Decreased mental effort? Y/N
Loses things Y/N
Easily Distracted Y/N
Forgetful Y/N
HYPERACTIVEAND IMPULSIVIVE SYMPTOMS (Need 5 or more symptoms for Hyperactive, Impulsive Type):
Often fidgets Y/N
Leaves seat Y/N
Maybe limited to feeling restless Y/N
Unable to engage in leisure activities quietly “Driven by a motor.” Y/N
Talks excessively Y/N
Blurts out Y/N
Difficulty waiting Y/N
Interrupts or intrudes on others Y/N

Developmental History of Symptoms (age onset? why seeking treatment now?)

What Is the Impact on Function?
Example 1:

Example 2:"

Providing Patients with Information and Educational Materials

After talking through some sleep hygiene principles with a patient, you could type the smartphrase:

.edInsomnia

And get the following text...

OP 10 SLEEP TIPS

#10 KEEP YOUR BEDROOM DARK

#9 GET LOTS OF NATURAL LIGHT IN THE MORNING. Go for a walk or buy a lightbox. Light and dark are the external signals controlling your circadian system, colloquially called the “circadian clock." Darkness tells your body to get ready for sleep and this is signaled in the brain through the release of melatonin (a neurohormone). Light does the opposite. It tells your body it’s time to be awake and alert.

#8 DON’T WORK ON YOUR COMPUTER LATE AT NIGHT OR IF YOU DO GET AN APPLICATION LIKE “FLUX" TO MINIMIZE THE AMOUNT OF BRIGHT LIGHT YOUR EXPOSED TO. “Flux" is a super cool application that controls your computer screen’s light output and tries to make it as natural as possible so that it mimics the actual time of day/night you are in; your computer screen will be brighter in the morning and dimmer at night.

#7 DON’T NAP DURING THE DAY. Sleep is linked to a homeostatic sleep drive. Basically, the longer you are awake, the more adenosine (a chemical metabolite) builds up in your body. The accumulation of adenosine correlates with the strength of your sleep drive, that’s why if you’ve been up for 24 hours straight you almost inevitably feel your eyelids becoming too heavy to lift up, and it’s hard or impossible to fight off sleep… Another cool fact is that caffeine works by antagonizing (acting against) adenosine, that’s why it’s a stimulant. So the point is… Let your sleep drive (and adenosine) build up. Don’t dissipate the strength of your natural sleep drive by taking a nap during the day!

#6 NO CAFFEINE 3 HOURS OR MORE AFTER WAKE UP TIME. See detailed explanation above for how caffeine works. Caffeine has a long half-life, so it’s hanging around in your system, making it harder for you to sleep if you drink it later in the day.

#5 ONLY USE YOUR BED FOR SLEEPING OR ROMANTIC ACTIVITIES. Your brain is smarter than you are. If you play video games, or do work on your laptop in bed, and then try to go to sleep, your brain will associate back to those activities, even if you don’t want it to. It’s like the classic example - “Don’t think about a white elephant.” You will probably find yourself thinking of the white elephant automatically or going back to the work in bed example thinking about your work.

#4 FIGURE OUT IF YOU'RE A NIGHT PERSON OR A DAY PERSON, and try to make your sleep schedule as natural as possible (while still showing up for work on time:).

#3 GET A RELAXATION ROUTINE BEFORE BED. This will be different for everyone. For some people, watching ESPN could be the most relaxing thing in the world. For others, listening to football players colliding could induce a state of wakefulness and irritation. So pick something that mellows you out - reading, a bath, vegetating to TV or the radio or a podcast, meditating - and start a routine of doing this 1 to 2 hours before your intended bedtime.

#2 IF YOU CAN'T GET TO SLEEP AFTER 15 TO 30 MINUTES GET OUT OF BED AND DO SOMETHING RELAXING. Probably the biggest driver of insomnia is anxiety about insomnia. Don’t lie there thinking about how tired you’re gonna be the next day. Get up, do something on your list from 5. above. When you start to feel sleepiness naturally coming to you, try to sleep again.

#1 DON’T DRINK ALCOHOL IN THE EVENING or limit alcohol to 1 drink. Alcohol makes most people sleepy but has a very short half-life (you metabolize about 1 beer an hour). Since alcohol stimulates the GABA system, and since GABA is a neurotransmitter system, which helps modulate relaxation, alcohol causes the opposite effect - anxious AROUSAL - when it is metabolized. Alcohol can be great for getting you to sleep but is terrible for keeping you asleep and disrupts the integrity of your sleep density (translation: reduces the quality of your sleep). People with anxiety-sensitivity can have this experience after even a single beer or glass of wine.

Documenting Difficult Decisions

Smartphrases are good for common but difficult decisions.

For example, to explain why a patient does not present an imminent danger of harm to self or others, we could type the following smart phrase:

.ratSafetyChronic

And the following text would autoinsert in the document:

“Safety risk is increased overall given multiple dynamic (we could type out any changeable, current risk factors here, such as 'active methamphetamine abuse, psychotic symptoms') and static ('we could type out any fixed or historical risk factors here, such as 'axis I - III, history of 2 previous suicide attempts') risk factors mitigated by protective factors, as documented above and/or in initial assessment. There was no indication of currently increased or imminent danger to self or others based on today's exam; outpatient care with close monitoring is appropriate.”

Or for medication management, if we decided to change multiple medications on the same visit, we could type the following phrase...

.ratMultipleMedicationChanges

And get the following text...

"Discussed r/b ratio for a more conservative, single-medication sequential change approach to pharmacotherapy versus more aggressive approach with multiple concurrent medication changes; potential risks include increased side effects and greater difficulty establishing cause and effect relationships; potential benefits include more rapid and/or robust therapeutic effects."

Automating Other Repetitive Tasks

Smartphrases can help to make simple but laborious things much faster. For example, if we need to insert our address at the top of a letter, we could type...

.address

And get the following...
University of Rochester Medical Center
Department of Psychiatry
300 Crittenden Blvd., Box Psych
Rochester, NY 14642

Recommended Text Expander Programs

The most popular text expanders are TextExpander for Apple's operating system and Breevy for Windows.

Table of Contents for Smartphrases in Psychiatry

C

Contracts (.contract) e.g. .contractBZ = treatment contract for prescribing a benzodiazapine

D

Diagnoses (.dx) e.g. .dxADHD = DSM criteria for ADHD with Y/N checklist to allow for rapid documentation of diagnosis

E

Educational material (.ed) for patients e.g. .edNutrition = nutrition education for patients who are overweight or on atypical antipsychotics

I

Informed consent (.ic) for medications e.g. .icAmantadine = a listing of the side effects associated with this medication.

L

Labs (.labs) for monitoring on specific medications and labs for work-up of neuropsychiatric conditions e.g. .labsClozapine = surveillance labs when prescribing clozapine, .labsDelirium = lab panels to assess for psychiatric and medical etiologies of delirium

Letters (.letters) and e-mails to patients and clinicians e.g. letterRareSideEffect = letter to patient with an explanation of the likelihood that this side effect is due to his or her psychiatric medication finding and recommendations for follow up

R

Rationale (.rat) for decision-making. As described in the introduction to smart phrases, this section is intended to facilitate complex medical decision-making. Some of the smart phrases have instructions for trainees in brackets [ ] for putting in patient specific information.

Rx (.rx) = prescription; have included the medication dosing and titration schedules I use most frequently e.g .rxLurasidone = uptitration for starting lurasidone.

S

Scales (.scales) for measuring psychiatric symptoms and related domains e.g. .screenDepressionHamilton = Hamiltion 17-item rating scale for major depressive disorder.

Screens (screen) or screening questions for medical and psychiatric conditions e.g. .screenStimulantsCardiac = cardiac questions to determine if a patient needs an EKG prior to starting a stimulant.

T

Templates (.temp) for note writing e.g. .tempIntake = intake note template.

Smartphrase Library

C

.contractScheduledDrugs
Scheduled Medication Treatment Contract

I, @NAME@, agree to undergo medication management with @SIGN@.

I agree to the following statements:

•     I will not take any mind/mood altering/illicit/addicting drugs unless authorized by @SIGN@
•     I will submit my urine and/or blood specimen for alcohol and drug tests at any time
•     If a urine screen is positive, I will participate in treatment for substance abuse
•     I will not accept any stimulant or benzodiazapine prescriptions from another doctor

I understand that not adhering to the contract may result in @SIGN@ modifying the treatment plan, including referring me to another provider with greater expertise in substance abuse and discontinuation of medications, which may be harmful in the setting of substance use.

______________________________     ______________
Patient or Guardian Signature                  Date

______________________________     ______________
Physician Signature                                 Date

#D

.diff = differential

.diffDelirium
Differential includes vascular, infectious, neoplastic, degenerative, autoimmune, metabolic, idiopathic or iatrogenic, traumatic, and toxic etiologies.

.dxADHD
The patient currently endorses or denies the following features of
ADHD based DSM-5:
INATTENTIVE SYMPTOMS (Need 5 or more symptoms for Inattentive Type)
Fails to give close attention to details Y/N
Difficulty sustaining attention Y/N
Does not seem to listen Y/N
Does not follow through easily side tracked Y/N
Has difficulty organizing Y/N
Decreased mental effort? Y/N
Loses things Y/N
Easily Distracted Y/N
Forgetful Y/N
HYPERACTIVEAND IMPULSIVIVE SYMPTOMS (Need 5 or more symptoms for
Hyperactive, Impulsive Type):
Often fidgets Y/N
Leaves seat Y/N
Maybe limited to feeling restless Y/N
Unable to engage in leisure activities quietly "Driven by a motor." Y/N
Talks excessively Y/N
Blurts out Y/N
Difficulty waiting Y/N
Interrupts or intrudes on others Y/N

DEVELOPMENTAL HISTORY OF SYMPTOMS (age onset? why seeking treatment now?)

WHAT IS THE IMPACT ON FUNCTION?
Example #1:
Example #2:

.dxAlzheimer
Cross-sectional and longitudinal data, including collateral history, deficits in (memory and learning, language, executive function, social cognition, perceptual-motor, complex attention) as captured on the MoCA above, and functional impairment affecting x, y, and z, are most consistent with a diagnosis of Alzheimer Disease (AD)

.dxCapacity
1. Patient is able to express a consistent choice: yes/no
2. Patient understands medical condition: yes/no
3. Patient understands the risks/benefits/alternatives of treatment and non-treatment: yes/no
4. Patient is able to rationally manipulate and integrate relevant information: yes/no

.dxDepression
Reports the following depressive symptoms:
-sustained and pervasive depressed mood
-anhedonia
-decreased motivation
-sleep disturbance characterized by
-low energy
-? appetite
-decreased concentration
-excess negative self-cognitions (hopelessness; low self-esteem; guilt)
-no pyschomotor retardation or agitation
-denies suicidal ideation, homicidal ideation
-functional impairment affecting

.dxMjWd
The patient denies or endorses the following features of cannabis withdrawal syndrome (CWS) based on DSM-V criteria (3 or > required):

Irritability: Y/N
Nervousness/anxiety: Y/N
Sleep difficulty: Y/N
Decreased appetite or weight loss: Y/N
Depressed mood: Y/N

One of the following physical symptoms such as abdominal pain, shakiness/tremors, sweating, fever, chills, or headache: Y/N

#E

.edAkathasia
Akathisia is a potential side effect of antipsychotic medications. It consists of feeling like you have to move or pace, and can be very uncomfortable. Some people have described it as “feeling like you’re crawling out of your skin.” It can be treated by lowering the dose of the antipsychotic, switching to a different antipsychotic, or taking a beta-blocker, such as propranolol.

.edAlprazolamBz
1. Alprazolam (Xanax) is not prescribed by our Clinics.

There are many reasons for this:
a. Xanax enters the brain very rapidly and this has been shown to increase the risk of becoming addicted
b. Xanax can often make anxiety worse in between doses as its levels in the brain decrease. This effect is called rebound anxiety.
c. The rebound anxiety often caused by Xanax also increases the likelihood that patients will require higher doses and become more dependent over time.

2. Benzodiazepines and benzodiazepine agonists, such as Ambien, are not prescribed to individuals who have had difficulties with alcohol or illicit substances within the past year.

The reason for this is that studies have demonstrated that patients with recent alcohol or drug addiction have a higher risk of relapse if started on a benzodiazepine or benzodiazepine agonist.

3. A benzodiazepine contract, which provides rules for safely using a benzodiazepine or benzodiazepine agonist, must be signed and followed by the patient to start and continue treatment with a benzodiazepine.

The reason for this is that benzodiazepines can cause significant harm, including death, if not taken correctly or combined with illicit drugs. Both the physician and patient must agree on safe prescribing practices.

4. Random drug testing is required for treatment with a benzodiazepine or benzodiazepine agonist.

The reason for this is the same as 3. above: when benzodiazepines are combined with alcohol, narcotics, or other sedatives they can cause the breathing center in the brain to shut down and result in death.

5. Benzodiazapines or benzodiazepine agonists should not be prescribed to patients taking an opioid narcotic.

Please see our handout explaining the reasons for this.

6. Benzodiazapines should not be combined with other benzodiazepines e.g. Klonopin with Librium or with benzodiazepine agonists.

The reason for this is that studies have not demonstrated safety or effectiveness for combining two different benzodiazepines.

.edDryMouth
Here are some suggestions for dry mouth:

1. Sip water regularly.
2. Chew sugar-free gum or suck on sugar-free hard candies to increase the flow/output of saliva.
3. Try over-the-counter saliva substitutes. Look for ones containing carboxymethylcellulose or hydroxyethyl cellulose.
4. Avoid over-the-counter antihistamines and decongestants because they can make your symptoms worse.
5. Add moisture to the air at night with a room humidifier.

.edInsomnia
TOP 10 SLEEP TIPS

#10 KEEP YOUR BEDROOM DARK

#9 GET LOTS OF NATURAL LIGHT IN THE MORNING. Go for a walk or buy a lightbox. Light and dark are the external signals controlling your circadian system, colloquially called the “circadian clock." Darkness tells your body to get ready for sleep and this is signaled in the brain through the release of melatonin (a neurohormone). Light does the opposite. It tells your body it’s time to be awake and alert.

#8 DON’T WORK ON YOUR COMPUTER LATE AT NIGHT OR IF YOU DO GET AN APPLICATION LIKE “FLUX" TO MINIMIZE THE AMOUNT OF BRIGHT LIGHT YOUR EXPOSED TO. “Flux"controls your computer screen’s light output and tries to make it as natural as possible so that it mimics the actual time of day/night you are in; your computer screen will be brighter in the morning and dimmer at night.

#7 DON’T NAP DURING THE DAY. Sleep is linked to a homeostatic sleep drive. The longer you are awake, the more adenosine (a chemical metabolite) builds up in your body. The accumulation of adenosine correlates with the strength of your sleep drive, that’s why if you’ve been up for 24 hours straight you almost inevitably feel your eyelids becoming too heavy to lift up, and it’s hard to fight off sleep… Caffeine putatively functions as a stimulant by antagonizing (acting against) adenosine receptors (Ribeiro JA, Sebastiao AM, J Alzheimers Dis, 2010). So the point is… Let your sleep drive (and adenosine) build up. Don’t dissipate the strength of your natural sleep drive by taking a nap during the day!

#6 NO CAFFEINE 3 HOURS OR MORE AFTER WAKE UP TIME. See detailed explanation above for how caffeine works. Caffeine has a long half-life, so it’s hanging around in your system, making it harder for you to sleep if you drink it later in the day.

#5 ONLY USE YOUR BED FOR SLEEPING OR ROMANTIC ACTIVITIES. Your brain is smarter than you are. If you play video games, or do work on your laptop in bed, and then try to go to sleep, your brain will associate back to those activities, even if you don’t want it to. It’s like the classic example - “Don’t think about a white elephant.” You will probably find yourself thinking of the white elephant automatically or going back to the work in bed example thinking about your work.

#4 FIGURE OUT IF YOU'RE A NIGHT PERSON OR A DAY PERSON, and try to make your sleep schedule as natural as possible (while still showing up for work on time:).

#3 GET A RELAXATION ROUTINE BEFORE BED. This will be different for everyone. For some people, watching ESPN could be the most relaxing thing in the world. For others, listening to football players colliding could induce a state of wakefulness and irritation. So pick something that mellows you out - reading, a bath, vegetating to TV or the radio or a podcast, meditating - and start a routine of doing this 1 to 2 hours before your intended bedtime.

#2 IF YOU CAN'T GET TO SLEEP AFTER 15 TO 30 MINUTES GET OUT OF BED AND DO SOMETHING RELAXING. Probably the biggest driver of insomnia is anxiety about insomnia. Don’t lie there thinking about how tired you’re gonna be the next day. Get up, do something on your list from 5. above. When you start to feel sleepiness naturally coming to you, try to sleep again.

#1 DON’T DRINK ALCOHOL IN THE EVENING or limit alcohol to 1 drink. Alcohol makes most people sleepy but has a very short half-life (you metabolize about 1 beer an hour). Since alcohol stimulates the GABA system, and since GABA is a neurotransmitter system, which helps modulate relaxation, alcohol causes the opposite effect - anxious AROUSAL - when it is metabolized. Alcohol can be great for getting you to sleep but is terrible for keeping you asleep and disrupts the integrity of your sleep density (translation: reduces the quality of your sleep). People with anxiety-sensitivity can have this experience after even a single beer or glass of wine.

.edlithium
A Practicum for Patients on Lithium

1) Taking lithium requires annual lab monitoring in addition to the initial series of labs.

2) Taking lithium requires careful attention to dosing and to interactions with othermedications.

Dosed appropriately, lithium is the gold standard treatment for bipolar disorder and iscapable of preventing future episodes of depression and mania.

However, excessively high blood levels of lithium can cause poisoning; severe lithiumpoisoning can result in coma, brain injury, and even death.

3) Your lithium levels can become dangerously increased when combined withmedications for your blood pressure (anti-hypertensives).

If you start, stop, or change the dose of a blood pressure medication, we may need tomonitor your lithium levels and adjust your lithium dose.

4) Your lithium levels can become dangerously increased if you take an anti-inflammatory medication, such as Ibuprofen.

The only over-the-counter, anti-inflammatory medications you can take on lithium areTylenol, Aspirin, and Sulindac (Lexicomp Drug Interactions, 2017).

5) Your lithium levels can become dangerously increased if you get dehydrated.

Hold your lithium dose and call me for any of these common causes of dehydration:-excessive sweating from hot weather
-fluid loss from diarrhea and/or vomiting

6) If you find yourself urinating more frequently after you begin taking lithium, youshould be evaluated by your primary care doctor for a condition called DiabetesInsipidus. This condition affects your body’s ability to regulate the excretion of fluids andcauses increased thirst and increased urination.

7) Approximately 10 to 20% of individauls taking lithium for 15 to 20 years or longerwill develop a gradual decline in their kidney functioning (UpToDate, 2017); we willmonitor your kidney functioning yearly.

8) Lithium decreases thyroid function in approximately 20% of individuals, who take itlong-term (Lazarus JH, 2009). However, for most people this decrease does not requiretreatment and/or can be normalized by taking thyroid hormone replacement withoutstopping your lithium.

7) If you decide to stop lithium, it should be done through a gradual taper process. Abrupt discontinuation of lithium increases your risk of a subsequent manic or depressiveepisode.

.edNutritionExercise
Nutrition/Meal Plans: See Whole 30 PDF and Program

http://whole30.com/whole30-program-rules/

Other acceptable foods for snacks and additions to your meals:
1) 2 pieces of fruit per day
2) Coffee with a little cream
3) Cottage cheese
4) Avocados
5) Any nuts - almonds, cashews, peanuts
6) Beef jerkey
7) Beans
8) All vegetables
9) Beverages: water, diet soda, sparkling water
10) If you need a desert, try a small amount of dark chocolate > 80% dark

Do not eat or drink:
1) Sodas with sugars
2) Fruit juice
3) Common carbohydrates - noodles, rice, bread, tortillas
4) No deserts - candy, cake, ice cream
6) No potatoes
Allowed: 1 cheat meal per week

Workout routine:
-3x per week: 10 to 15 minutes of walking or swimming, with 4 sets of intervals consisting of 30 seconds at increased intensity (60 to 70% max = breathing heavy)

.edNutritionWillett
Ask the Expert: Controlling Your Weight
Updated by Dr. Willett for Dr. Soskin and his organization to use in clinical practice; permission for dissemination granted by Dr. Willett.

Dr. Walter Willett
Fredrick John Stare Professor of Epidemiology and Nutrition,
Departments of Nutrition and Epidemiology, and Chair, Department of Nutrition, Harvard School of Public Health

Related Articles
How to Get to Your Healthy Weight: Learn more about the relationship between weight and chronic disease, and get tips for achieving or maintaining a healthy weight.

How much control do we have over our body weight? And how much of our weight is controlled by our genes?

Genes do play a role in controlling our weight, but clearly they do not explain the huge increases in overweight and obesity we have seen in the last 30 years. We gain weight when our "calories in” (the food we eat) exceeds our "calories out" (the energy we burn). Given the genetic package we are born with, we can all improve our weight by paying attention to diet and getting regular physical activity, but some people will need to work harder than others to maintain a healthy weight. In other words, if we all eat and work out the same, we will not all look the same. Only a very small percentage of people have such a strong genetic predisposition that they will be obese no matter how hard they try. Even people who are genetically predisposed to obesity can reduce their risk of chronic disease by eating a healthful diet and staying active.

What is the best diet for losing weight?

The real issue is not losing weight-people can cut back on calories and lose weight on almost any diet-but keeping weight off over the long run. Thus it is more important to find a way of eating that you can stay with for the rest of your life. For this reason, any eating plan you choose should be satisfying and allow variety, and should also be nutritionally sound.

The most successful dietary weight control study has been Dr. Iris Shai in Israel with Dr. Meir Stampfer in our department of nutrition. This study compared three diets: a low fat diet, a Mediterranean Diet, and a healthy higher fat diet. After 18 months the low fat diet was the least effective. Most importantly, after six years, weight loss was maintained best with the Mediterranean diet, and blood indicators of metabolic status were also superior.

If you are interested in following this type of eating plan, I suggest using the Harvard School of Public Health's Healthy Eating Pyramid and Healthy Eating Plate as a guide. Like the Mediterranean diet used in the weight loss study, the Healthy Eating Pyramid emphasizes fruits, vegetables, whole grains, nuts and legumes, healthy oils, and daily physical activity. To lose weight, watch your portion sizes and aim for a modest reduction in your daily calorie intake. My recent book with Mollie Katzen, Eat, Drink and Weigh Less (Hyperion, 2006), follows the same nutritional principles as the Healthy Eating Pyramid and details many eating strategies for weight control.

The Nine Turning Points
Following these diet and lifestyle guidelines can help you achieve a healthy weight and reduce your chronic disease risk:

1. Eat lots of vegetables and fruits.
2. Say yes to good fats.
3. Upgrade your carbohydrates.
4. Choose healthy proteins.
5. Stay hydrated.
6. Drink alcohol in moderation (optional).
7. Take a multivitamin every day.
8. Move more.
9. Eat mindfully all day long.

Source: Katzen M, Willett WC. Eat, Drink and Weigh Less: A Flexible and Delicious Way to Shrink Your Waist Without Going Hungry. New York: Hyperion; 2006. p.14-15.

Can I lose weight through diet alone? Or do I need to exercise, too?

Daily physical activity can help you control your weight and can reduce your risk of chronic disease. That's why it is the foundation of the Harvard School of Public Health's Healthy Eating Pyramid. Aim for at least 30 minutes a day of physical activity; many people will find that 60 minutes a day is helpful for weight control. For more information on the benefits of physical activity, read the article about staying active.

Will going on a low-carbohydrate diet help me lose weight?

Some people who go on a low carbohydrate diet have managed to keep weight off, but the best studies show that on average the weight loss is small after one year. There has been much debate about the impact of low carbohydrate diets on overall health. Our recent 20-year study on 82,080 women found that that a low carbohydrate eating pattern did not increase risk of heart disease; if the protein and fats mainly came from vegetable sources, a low carbohydrate eating pattern actually reduced heart disease.

Should I cut back on fat to lose weight?

The goal is to cut back on calories, and a common mistake is to focus only on fat. Fat is satisfying, and in the long run low fat diets have generally failed as a way of weight control. For good health, the type of fat is more important than the amount; eat plenty of unsaturated fats, limit saturated fat, and avoid trans fat. For more information on how to choose healthy fats, read the article about Fats & Cholesterol.

What are the best fruits and vegetables to eat if I want to lose weight? Which fruits and vegetables should be avoided?

Choose a wide variety of vegetables and fruits every day, but don’t include white potatoes as a vegetable. Potatoes are a starch, and a rapidly-digested one at that; nutritionally, they have more in common with white bread and white rice than with other vegetables, and they should be eaten only occasionally. Go easy on fruits that are higher in carbohydrate, such as oranges, bananas, apricots, cherries, grapes, mangoes, pineapple and pears. Also, avoid fruit juices, since they contain a lot of sugary calories; choose whole fruit instead, since it has more fiber and will make you feel more full.

Which type of protein is best for me to eat-vegetable protein or animal protein?

Emphasizing vegetable over animal sources of protein will help reduce risk of heart disease. For example, this means eating nuts, beans, and soy products instead of red meat, which contains a lot of saturated fat and cholesterol. However, a healthy diet can include moderate amounts of poultry, fish, and eggs.

Will drinking milk or eating yogurt help me lose weight?

Long term studies do not show a benefit of milk for weight loss, which should be no surprise as even low fat versions still contain quite a few calories. Recent studies do suggest that men and women who consume yogurt regularly have less long term weight gain, but more research is needed.

Every month, I read about a new type of diet that promises to help me lose weight fast. How can I tell if a diet is safe and effective?

Rigid diets usually fail in the long run. I would be wary of any diet that eliminates entire food groups or drastically reduces one food component (such as diet that is very low in carbohydrates). Diets that recommend skipping meals or replacing meals with special supplements are also suspect.

Will supplements such as conjugated linoleic acid, omega 3 fish oil, or vitamin B6 help me lose weight?

None of these supplements have been shown to reduce weight. A multiple vitamin is a good nutritional safety net for most people, and for premenopausal women it is good to use a preparation that includes iron.

How can I find out how much I should weigh?

There is no single number that works for everyone. Your body-mass index, or BMI, a ratio of weight to height, is one way to tell if you are at a healthy weight (you can calculate your BMI online). Almost everyone should try to keep their BMI below 25. Also, keep in mind that most of the weight we gain in adulthood is fat. So unless you were clearly underweight at age 18 or 20, it is best not to gain more than 5 or 6 pounds after this age. For someone who is very overweight, it is usually not realistic to go all the way back to your weight at age 18; even a 5 to 10 percent weight loss has important health benefits.

How often should I weigh myself?

Once a week is a good interval. It is also a good idea to keep an eye on your waist circumference; even an inch or two increase in waist size is a sign that you may need to cut back or calories, exercise more, or both."

For more information on diet and nutrition go to Dr. Willet's website:
http://www.hsph.harvard.edu/nutritionsource/weight-control/

Book Recommendations:
Eat, Drink, and Be Healthy: The Harvard Medical School Guide to
Healthy Eating by P.J. Skerrett (Afterword, Contributor), walter
willett M. D. (Author)
Weight loss: Eat, Drink, and Weigh Less: A Flexible and Delicious Way
to Shrink Your Waist Without Going Hungry Paperback by Mollie Katzen
(Author), Walter Willett (Author)

.edTSH
The TSH is a measure of thyroid function - the higher number, the harder your thyroid is having to work to produce active thyroid hormones. If it is too high, it indicates your thyroid is not working well enough. Thyroid abnormalities can cause or contribute to psychiatric problems, so it’s important to keep your thyroid in a healthy range.

.edValproicLabs
Because there is a low risk that valporate or divalproex could cause harm to your liver and/or decrease your production of platelets, we will need to have your blood drawn according to the schedule below. We will be measuring your liver functioning and your platelet production; we will also find out how much of the medication is active in your system.

Schedule of lab draws for patients taking valproate or divalproex:
-Before starting on the medication
-2 weeks after starting on the medication
-6 months after starting on the medication
Then, thankfully:)!, you will only need to have your blood drawn yearly, unless there is another clinical reason for it.

.icAmantadine
Informed consent disclosed; discussed possible cardiovascular, gastrointestinal, neurologic, and psychiatric adverse effects. Discussed non-ahderence/abuse. Warned.

.icAntipsychotic
Informed consent disclosed. Discussed neurological and metabolic side effects. Discussed non-ahderence/abuse. Warned.

.icAntipsychoticF
Informed consent disclosed. Discussed neurological side effects, including acute dystonia, akathisia, extrapyramidal symptoms, tardive dyskinesia, and sedation; metabolic side effects, including hyperglycemia, hyperlipidemia, and weight gain; data that for patients with dementia use of atypical antipsychotics has been associated with a slightly increased risk of death (increased from approximately 2% to 4%) and stroke (0.5% increased to 1.5%). Discussed non-ahderence/abuse. Warned.

.icAtomexetine
Discussed risks/benefits/alternatives to atomexetine, including GI side effects, weight loss, irritability, constipation, sexual dysfunction, increase in blood pressure,and liver damage, and patient agrees to trial. Patient denies any h/o cardiovascula rdiscease, including hypertension, tachyarrhythmias, or structural cardiac abnormalities.

.icBenzodiazapine
Discussed risk of motor impairment, cognitive impairment, sedation, dependence, tolerance, abuse, withdrawal sequelae, accidental overdose, life-threatening respiratory depression (particularly in combination with alcohol and/or opioids), excess sedation if combined with other sedating medications.

.icBupropion
Informed consent disclosed; discussed seizures, anxiety, agitation, switch, destabilization of mood. Discussed non-ahderence/abuse. Warned.

.icBuspirone
Informed consent disclosed; discussed dizziness, headache, nervousness, sedation, excitement, gastrointestinal side effects. Discussed non-ahderence/abuse. Warned.

.icClonidine
Informed consent disclosed; discussed sedation, dizziness, bradycardia, hypotension, cardiac risks, rebound hypertension. Discussed non-ahderence/abuse. Warned.

.icDuloxetine
Informed consent disclosed; discussed discussed anxiety, activation, insomnia, suicidality, switch, increase in blood pressure and heart rate for duloxetine. Discussed non-ahderence/abuse. Warned.

.icGabapentin
Informed consent disclosed. Discussed oversedation, dizziness, withdrawal seizures; non-compliance/abuse. Warned.

.icGlycopyrrolate
Informed consent disclosed. Discussed flushing, constipation, nausea/vomiting, cardiac, respiratory, and neurologic side effects. Discussed non-ahderence/abuse. Warned.

.icGuanfacine
Discussed orthostasis, abdominal pain, gastrointestinal side effects, dizziness, headache, hypotension, sedation, syncope, bradycardia, insomnia, sexual side effects for guanfacine. Discussed non-ahderence/abuse. Warned.

.icLamotrigineSJS
Patient advised of risk of possibly fatal rash (i.e., Stevens-Johnson Syndrome) in 1:10,000 individuals, and agrees to stop medication, and seek medical attention immediately if rash or blistering of the mucosal surfaces develop; also dicussed higher rate (approximately 10%) of benign drug-induced rash, and patient agrees to stop medication and seek medical attention immediately if any rash occurs, given the potential for lethality and requirement for evaluation by a physician to rule this out. Patient further advised that the risk of this reaction increases if proper dose titration is not adhered to carefully, and that not taking this medication for 2 days or more will require a retitration process, and, therefore the patient should not restart at previous dose, but call me immediately for instructions on how to retitrate.

.icLevothyroxine
Informed consent disclosed; discussed palpitations, alopecia, sweating, weight loss, diarrhea, insomnia, anxiety, fatigue, myocardial infarction, secondary to coronary spasm, decreased bone mineral density, hip fracture, pseudotumor cerebri, seizure for levothyroxine. Discussed non ahderence/abuse. Warned.

.icLightbox
Discussed potential benefits of chronotherapy as a well-studied augmentation strategy (even for patients without a seasonal component to their depression) and as a tool for stabilizing circadian rhythms, advancing sleep phase, and alleviating difficulty falling asleep if used in the morning on a consistent basis; discussed risks including headache, jitteriness, anxiety, or in some rare cases, mania or hypomania.

.icLithium
Informed consent disclosed for lithium; discussed toxicity, drug-drug interactions, rebound mood effects with discontinuation, rebound suicidality, gastrointestinal, renal, and endocrine side effects; non-compliance/abuse. Warned. Handout given.

.icLithiumTaper
Informed consent disclosed; discussed risks of rebound mood destabilization and increased suicidality with lithium taper. Discussed non-ahderence/abuse. Warned.

.icMirtazapine
Informed consent disclosed; discussed anxiety, activation, sedation, metabolic side effects, suicidality, switch. Discussed non-ahderence/abuse. Warned.

.icModafinil
Informed consent disclosed; discussed insomnia, anxiety, agitation, headache, hypertension, anorexia, toxicity, abuse liability. Discussed non-ahderence/abuse. Warned.

.icNaltrexone
Informed consent disclosed; Discussed anxiety, insomnia, low energy, headache, mood changes, joint and muscle pain, gastrointestinal side effects, syncope, liver injury for naltrexone. Discussed non-ahderence/abuse. Warned.

.icOxcarbazepine
Informed consent disclosed; discussed ataxia, dizziness, headache, fatigue, nausea, somnolence, and visual disturbances for oxcarbazepine. Discussed non-ahderence/abuse. Warned.

.icPramipexole
Informed consent disclosed. Discussed orthostatic hypotension, nausea, amnesia, cognitive side effects, headache, constipation, somnolence, insomnia, vivid dreams, sleep attacks, hallucinations. Discussed non-ahderence/abuse. Warned.

.icPrazosin
Informed consent disclosed; discussed dizziness, fainting, drowsiness, decreased energy, and headache for prazosin. Discussed non-ahderence/abuse. Warned.

.icPropranolol
Informed consent for propranolol disclosed; discussed dizziness, fatigue; cardiovascular, respiratory, dermatological potential side effects; non-compliance/abuse. Warned.

.icSildenafil
Informed consent disclosed for viagra; discussed priapism, cardiovascular, ophthalmic, and otic risks/side effects; noncompliance/abuse discussed. Warned.

.icSSRI
Informed consent disclosed; discussed anxiety, activation, insomnia, suicidality, switch, withdrawal syndrome. Discussed non-ahderence/abuse. Warned.

.icSSRIdc
Patient advised of risk of withdrawal syndrome, as well as possibility of return of primary depressive symptoms, and patient gives informed consent.

.icStimulant
Informed consent disclosed; discussed insomnia, anxiety, agitation, anorexia, autonomic effects, toxicity, psychosis, abuse liability. Discussed non-ahderence/abuse. Warned.

.icTCA
Informed consent disclosed; discussed potential for toxicity/lethality, cardiac risks, seizure risks, anticholinergic and antihistaminic side effects, serotonin syndrome. Discussed non-ahderence/abuse. Warned.

.icTrazodoneMale
Informed consent disclosed. Discussed excess sedation, orthostasis, cognitive impairment, priapism for trazodone. Discussed non-ahderence/abuse. Warned.

.icTrazodoneFemale
Informed consent disclosed. Discussed excess sedation, orthostasis, cognitive impairment for trazodone. Discussed non-ahderence/abuse. Warned.

.icVarenicline
Discussed risks, benefits, and alternatives to varenicline, including common side effects of GI upset, insomnia, and headaches, as well as serious side effects such as mood lability, suicidal thinking, and increased risk of heart attack and strokes. Patient understands these risks and consents to treatment.

.icValproicAcid
Informed consent disclosed; Discussed gastrointestinal side effects, neurological side effects (dizziness, sedation, tremor), opthalmic side effects (blurred vision, diplopia, amblyopia), liver failure, pancreatitis, thrombocytopenia, hyperammonemia. Discussed non-ahderence/abuse. Warned.

.icVenlafaxine
Informed consent disclosed; discussed discussed anxiety, activation, insomnia, suicidality, switch, increase in blood pressure and heart rate, withdrawal syndrome for venlafaxine. Discussed non-ahderence/abuse. Warned.

L

.labsCarbamazepine
Baseline: CBC
1 month: CBC, LFTs, carbamazepine level, serum sodium
Then yearly: CBC, LFTs, serum sodium, carbamazepine level

.labsClozapine
Will check UA, CBC w/diff, ANC, ALT/AST, BUN/Cr, FBS, Fasting Lipid Panel prior to initiating Clozaril. Will then check ANC q1week x 6 months, then q2 weeks x 6 months, then q1 month. Will check FBS and Fasting Lipid Panel q3 months x 1 year and then once annually thereafter.

.labsDelirium
If not performed and/or pending, critical to obtain the following labs and values - Stox and Utox, VS, prn O2, non-contrast CT – to help rule out acutely life-threatening etiologies (Wernicke’s, hypoxia, hypoglycemia, hypertensive encephalopathy, hyper or hypothermia, intracerebral hemorrhage, meningitis/encephalitis, substance-induced toxicity).

Obtain additional diagnostic data:
-repeat CBC with diff, chem 10, LFTs, UA with culture
-add TSH, B12, folate, RPR, HIV
-consider neuroimaging to evaluate for structural CNS etiologies

Check pre-haloperidol QTc interval
-If QTC > 450 ms, proceed with care
-If QTC > 500 ms, consider alternative treatments

Check potassium and magnesium, and correct abnormalities
-Replete to K > 4 and Mg > 2
-Check K and Mg daily if administering an antipsychotic and replete to K >4 and Mg >2

Avoid benzodiazepines, anticholinergics, minimize opioids, as these agents may contribute to delirium

.labsLithium
Baseline: TSH, BUN/Creatinine, antithyroid peroxidase antibody titers
2 weeks: lithium level, TSH, BUN/Creatinine
6 months: TSH, BUN/Creatinine
Then yearly: TSH, lithium level, chem 7

.labsOxcarbazepine
Baseline: serium sodium
1 month: serium sodium
Then prn if concern for hyponatremia

.labsTopiramate
Baseline: bicarbonate
1 month: bicarbonate
Then prn if concern for metabolic acidosis

.labsValproic
Baseline: LFTs, CBC
2 weeks: LFTs, CBC, Depakote level
Then yearly: LFTs (more frequent if concern for hepatitis), CBC (more frequent if easy bruisability)

.letter = letters or e-mails
For convenience, I’ve grouped both letters and e-mails to patients or staff under the category, letter.

.letterBupropionAndAnxiety
Interesting question regarding Wellbutrin...
The answer is it depends: in large studies it has been shown to help reduce anxiety as well as depression; however, it appears to work slightly less well for anxiety than serotonergic agents (like Prozac, Paxil etc); and, as we talked about, for some people it can increase anxiety, particularly in the beginning, giving you a surge of energy/activation similar to feeling jittery or over-caffeinated.

.letterMedicationRefillWarning
Hi Mr. X,

I received your request for a refill of your ***.
I have written a new prescription for you for a 2 week supply.
However, I will need to see you in the office again within the next 2 weeks to be able to continue prescribing this medication.
Hope you're doing well and look forward to seeing you soon!

.letterElevatedGlucose
Dear Dear @M@ @LNAME@,

All of your labs were normal, with the exception of your fasting *** level, which was high. This could indicate an increased risk for or the presence of diabetes.

Please feel free to call me at @TEL@, if you have additional questions about this finding.

Since there is always the possibility of lab error or a false lab value if the lab test was performed too soon after a meal, I have reordered the lab test or you.

It would be great if you could have it done about 12 hours after your last meal.

I am forwarding the lab result to your primary care physician, and ask that you also follow-up with your primary care physician.

Many thanks!
Dave Soskin MD

.letterMissedWork
Dear Sir or Madame,

Please excuse @NAME@ from work from x to y due to medical reasons.

Sincerely,

David Soskin MD

.letterRareSideEffect
Dear @M@ @LNAME@,

I am sorry to hear this!!

I reviewed the literature on this agent, and x is not reported as a common side effect.

Also, the timing of your *** is slightly unusual for a drug side effect, since we typically see a connection in time between when a medication is started and the onset of the side effect.

I have the following suggestions:

1) Call your primary care physician, and describe your symptoms - the primary care doctor or nurse can determine if you need a medical evaluation.

2) If your primary care physician can't find an explanation, then we may need to take you off the medication. Everyone responds to medications very differently. Even though a side effect isn't reported in the literature, or it is reported as unlikely to occur, it is still possible that in your case it is related to the medication.

Hope this helps!
Dave Soskin MD

.letterRefillTooEarly
Dear @M@ @LNAME@,

I saw that you had requested a refill for ***.

It appears that your refill is not due until ***; I can refill this medication 2 to 3 days in advance for pick-up in the pharmacy and 7 days in advance for mail order.

If you think there has been a mistake in calculating the new refill date, or if you have questions or concerns regarding this, please give us a call.

Best wishes,
Dave Soskin MD

.letterRnPhoneFu
Dear ***,
Thanks so much! Will you give the patient a call back and obtain the following information using the template below. Many thanks, Dave

1) Persistent or interval symptoms?
2) Taking medication as prescribed?
3) Any medication questions, concerns, or side effects?
4) Patient needs appointment, or patient can get future refills from PCP?

Thanks.
@ME@

.letterSJS
Dear Staff,

Can you call this patient and ask him/her to see his/her primary care physician today?

If the patient is unable to see his/her primary care physician today, he/she needs to go to the ER.

Although it is unlikely that the patient is developing SJS, since it is potentially lethal, we need to rule out this low probability event immediately.

The patient should not take any lamotrigine until he/she has seen a primary care or ED physician and been cleared of any drug-related side effects.

Thanks so much!
David Soskin

.letterStimulantExplanation
To whom it may concern:

@M@ @NAME@ is currently under my care. I have prescribed, and he is taking a medication called Adderall, which may be detected as amphetamine on a drug test. Unlike the illicit drug, methamphetamine, Adderall has been demonstrated to be safe and effective when taken appropriately for specific medical conditions. Thank you for your understanding.

Sincerely,

David Soskin, MD

.letterTransferToPCP
Dear Dr. ,
To improve access for more complicated and acutely ill patients, our Department is seeking to transfer care of stable patients like @PATIENT@ back to their PCPs.

@M@ @NAME@ also meets the criteria (below), which we developed to help determine if it is appropriate to transfer stable patients back to primary care:
-The patient has achieved remission on the the medication regimen above for at least 1 year
-The patient has no active suicidal ideation (plan, intent, means), and has been assessed as low risk for safety concerns
-The patient has demonstrated reliable communication skills with providers and has agreed to inform both of us, if there are any significant changes or concerns related to his or her psychiatric condition
-The patient has no history of substance abuse within the past year
-The patient has no history of psychiatric hospitalizations within the past two years

We hope that you are agreeable to this transfer of care. We are happy to be consulted or to have the care of @M@ @LNAME@ transferred back to our clinic should any concerns or questions arise. @M@ @LNAME@ also understands that he can return to our care at any time if needed.

Best wishes,
David Soskin MD

R

.rat = rationale

.ratBzRapidTaper
I explained the following reasons for rapidly tapering the patient’s benzodiazapine in the setting of alcohol abuse:

1) There is strong evidence that prescribing benzodiazapines to patients who are abusing alcohol increases their risk of relapse;

2) The combination of alcohol and benzodiazapines can be lethal, as it suppresses the respiratory center in the brain. Patients abusing alcohol are at higher risk of death from overdosing on benzodiazapines.

.ratMJ
Psychoeducation done regarding marijuana; potential depressogenic, anxiogenic, and psychotogenic effects; potential blunting of therapeutic psychotropic effects. Motivational framework taken.

.ratMultipleMedicationChanges
Discussed r/b ratio for a more conservative, single-medication sequential change approach to pharmacotherapy versus more aggressive approach with multiple concurrent medication changes; potential risks include increased side effects and greater difficulty establishing cause and effect relationships; potential benefits include more rapid and/or robust therapeutic effects.

.ratPolypharmacyInsomnia
Given the biological heterogeneity and multiplicity of the neural mechanisms modulating wake and sleep, we decided on low dose, judicious polypharmacy as a strategy for refractory insomnia with the objective of targeting additional neurotransmitter and/or neurohormonal systems and potentially minimizing side effects from high dose monotherapy; discussed risk of side effects stemming from pharmacodynamic interactions among multiple hypnotics used in polypharmacy approach; discussed difference between additive and synergistic pharmacodynamic effects, and warned regarding synergy related to current polypharmacy, discussed the need to ensure safety through test-dosing, monitoring, and appropriate safety parameters (e.g. Do not drive if sedated in the morning!); also discussed risk of synergistic pharmacodynamic side effects with alcohol and/or other sedating agents patient may purchase over the counter or be prescribed by another physician. Warned.

.ratPseudoResistance
We explored the following potentially confounding factors:
-inadequate duration of medication trial
-behaviors dampening or precluding medication effects, such as substance abuse
-medication non-adherence
-misdiagnosis or presence of undiagnosed co-morbidity

.ratPsychoeducationBipolar
Psychoeducation done on importance of maintaining stable social and circadian rhythms; identifying triggers and signatures of mood changes; communicating with providers to facilitate appropriate interventions; reducing conflict and overstimulation in relationships.

.ratSafetyChronic
Suicide risk is increased overall given multiple dynamic (***) and static (***) risk factors, mitigated by protective factors, including *** (consider: strong future-orientation, hopefulness, engagement with treatment, close relationships). Homicide Risk: ***. There was no indication of currently increased or imminent danger to self or others based on today's exam; outpatient care with close monitoring is appropriate.

.ratValproicAcidDementia
Based primarily on uncontrolled trials and a retrospective study, valproic acid at relatively low doses (ie, 7-12 mg/kg per d), with serum levels between 40 and 60 mcg/mL, are associated with improvements in agitation in some patients with dementia (Dolder, J PharmPract, 2012); additionally, valproic acid has been reported to be effective for the treatment of delirium, delirious mania, and catatonic features (Vaudev, BMJ Case Report 2010; Alam, J Neuropsychiatry Clin Neurosci 2014).

.rx = prescription

.rxAtomexetineAdult
Atomexetine 40 mg daily; after 7 days, can increase to 80 mg once in the morning or 40 mg in the morning and 40 mg at bedtime.

.rxBenzodiazepineTaper

1.    Convert to longer-acting agent (see benzodiazepine conversion table from Ashton Protocol: http://www.benzo.org.uk/manual/bzcha01.htm#24), or taper with the agent that the patient is taking.

•    Recommend longer-acting agents including clonazepam, diazepam, chlordiazepoxide.

•    For elderly patients, avoid or be cautious with diazepam and chlordiazepoxide; both produce the active metabolite, desmethyldiazepam, which has a half-life of 50 to 100 hours, and can accumulate to cause prolonged sedation. Remember also that the hepatic isoenzyme 3A4, which metabolizes diazepam, often becomes sluggish/hypo-functional in the elderly (APA Textbook of Psychopharmacology, 4th Edition, Chapter 12 written by Craig Nelson).

•    For patients with impaired hepatic metabolism, only use lorazepam, oxazepam, or temazepam.

•    Remember that equivalences are approximate; if converting, adjust the initial dose according to symptoms.

2.    Taper by no more than 5 mg diazepam equivalent per week.

•    Halt or reverse taper if severe anxiety or depression occurs.

•    Dispense daily, 2x weekly, or weekly depending on dose and patient reliability.

3.    When the taper dose is below 20 mg of diazepam equivalent, slow the rate of taper to 1 to 3 mg diazepam equivalent per week.

4.    *Do not apply this protocol to patients with active polysubstance abuse superimposed on concomitant use of benzodiazepines and opioids, as these patients may require an inpatient detox.

Adapted from Canadian Guidelines, 2016.

.rxBupropionXL
Bupropion XL 150 mg in the morning for 5 days; if well-tolerated, increase to 300 mg in the morning.

.rxBuspirone
Busprione 15 mg two times daily; increase by 5 mg every 3 days to target dose of 60 mg daily; can divide dosing into three times daily (best studied, e.g. 15 mg in morning, afternoon, and at bedtime) or two times daily (less likely to forget/easier, e.g. 30 mg in the morning and at bedtime).

.rxClomipramineFluvoxamineOCD
Days                               AM                                  PM
1-10                      fluvoxamine 50 mg                clomipramine 50 mg
11-20                    fluvoxamine 100 mg              clomipramine 100 mg
21 and after          fluvoxamine 150 mg              clomipramine 150 mg

.rxDuloxetine
Start at 40 mg in the morning for 5 days; if well-tolerated, increase to 60 mg in the morning.

.rxGabapentinSleep
Take 100 mg at bedtime. Can increase by 100 mg per night as needed for insomnia. Hold for oversedation or dizziness. Do not exceed 900 mg.

.rxGlycopyrrolate
Take 0.5 mg in the morning and at bedtime; okay to increase by 0.25 mg per day until effective or until you reach a total daily dose of 4 mg.

.rxHaloperidolIVDelirium
Protocol for IV Haldol in Agitated Delirious Patients
1) Check pre-haloperidol QTc interval If QTC > 450 ms, proceed with care If QTC > 500 ms, consider other options (see #6).

2) Check potassium and magnesium, and correct abnormalities. Aim for potassium > 4 mEq/L, magnesium > 2 mEq/L.

3) Initial dose:
Give initial dose of haloperidol (0.5-10 mg) based on level of agitation and age:
Elderly: 0.5 mg
Mild agitation: 2 mg
Moderate agitation: 5 mg
Severe agitation: 10 mg

Goal is to have patient calm and awake. Haloperidol precipitates with phenytoin and heparin; flush line before giving haloperidol if these agents have been used in the IV tubing.

4) Subsequent doses:
-Wait 20-30 minutes. If patient remains agitated, double the dose. Continue to double the dose every 30 minutes until patient is calm. Continue to give haloperidol, if the patient is only partially calm, as incomplete control of agitation will likely prolong the delirium and increase the total dose of haloperidol given to the patient.
-Note: you should obtain EKGs and check QTc prior to the second and third doses of haloperidol administered to assess for lengthening. If QTcs are < 450, can increase interval EKG monitoring to q 24 hrs. If QTc increases by 25% or becomes > 500, consider alternative treatments and monitoring frequency (see # 5).
-Once the effective dose has been determined, use that dose for future episodes of agitation
-Depending on likely course of delirium, may schedule haloperidol or give prn (e.g. may divide previous effective dose over next 24 hrs giving q6 hrs). Consider small doses (1 to 3 mg) at night to regulate sleep-wake cycle in all delirious patients.

5) Additional safety information when using IV haloperidol:
The rationale for using IV haloperidol rather than PO or IM is that it is less likely to produce EPS, and has superior absorption; additionally, it is less likely to increase paranoia, cause discomfort, or confound interpretations of muscle enzyme studies compared to IM administration; remember that IV and IM haloperidol are 2x as potent as PO haloperidol
The maximum total dose of IV haloperidol has not been established; IV administration of 200 mg in a single dose (Teaser, Murray, Cassem, J Clin Psychopharmacol, 1985) and 2000 mg in a 24-hour period (Sanders, Stern, O’Gara, Psychosomatics, 1992) have been reported.

QTc: if QTc is > 500 or is increasing > 25%, consider switch to Zyprexa or Abilify as they seem to be least associated with QTc prolongation. If continuing to use antipsychotics, follow QTc closely i.e. prior to each antipsychotic administration, monitor electrolytes closely, particularly K/Mg, and aggressively replete. Primary team should discuss and analyze R/B/A on an individual patient basis. Alternatives include temporizing measures, such benzodiazapines, opioids, anticonvulsant mood stabilizers; of note, benzodiazapines and opioids may help to control and contain symptoms of delirium in the short-term but may also be associated with worsening of mental status in delirious patients. If QTc > 550, strongly consider temporizing measures, alternatives to antipsychotics above, as R likely > B at this length of QTc. After large doses of haloperidol, a pressor other than epinephrine (e.g., norepinephrine) should be used to avoid unopposed beta-adrenergic activity

Sources:
Stern, T. et al,, MGH Handbook of General Hospital Psychiatry, 2010
Stern, T. Huffman, J. Primary Care Companion J Clin Psych, 2003
The MGH/McLean Psychiatry Residents' Handbook, 2009-2010

.rxIvanGoldbergHairLossFormula
Inositol 100 mg BID
Pantothenic Acid 100 mg TID
Zn 50-100 mg qd
BIotin 50mg po tid
Should work within 2 months if it is going to help.

.rxIvanGoldbergTrichSkinPicking
1. Start Naltrexone 25 mg/d for three days, then 50 mg/d
2. Start Anafranil 25 mg bid, with increases of 25 mg/d every three days up to 75 mg bid.
3. In one week, start Buspar and gradually increase up to 30 mg bid.

.rxLibriumProphylaxis
We agreed on the following intervention to help prevent alcohol withdrawal:
1. Loading dose: Librium 50 mg x 1
2. Then Prophylaxis: Librium 50 mg q6 hrs x 1 day; decrease to Librium 50 mg q 6 hrs x 2 days; discontinue

.rxLurasidoneAugmentation
Lursidone 20 mg at bedtime for days 1-2, 40 mg at bedtime for days 3-4, then increase to 60 mg at bedtime; must be taken with food or within 30 minutes of eating; meal or snack must contain 350 calories or more.

.rxLurasidoneMonotherapy
Lurasidone 20 mg at bedtime for days 1-2, 40 mg at bedtime for days 3-4, 60 mg at bedtime for days 5-6, 80 mg at bedtime on day 7; must be taken with food or within 30 minutes of eating; meal or snack must contain 350 calories or more.

.rxNaltrexone
Naltrexone 25mg daily for 7 days, then 50 mg daily. Patient advised of side effects, including risk of liver toxicity, GI side effects, and potential blockage of opiate pain medications, and gives informed consent. Advised to carry a card in wallet noting that he/she takes Naltrexone.

.rxPramipexole
Pramipexole 0.125 mg 2 to 3 hours before bedtime; if well-tolerated, okay to increase by 0.125 mg every 1 to 2 weeks until effective or until you reach a maximum dose of 0.75 mg.

.rxPregabalin1
Pregabalin 75 mg at bedtime for 4 nights; if well-tolerated, okay to increase to 1 capsule (75 mg) in the morning and 1 capsule (75 mg) at bedtime for 4 days; if well-tolerated, increase to 2 capsules (150 mg) at bedtime and 1 capsule (75 mg) in the morning; hold for sedation, dizziness, ataxia.

.rxPregabalinDowntitration
Decrease pregabalin by 75 mg every 4 days.

.rxPropranololAkathisia
Propranolol 10 to 20 mg for akathisia (a feeling of intense restlessness in your body, like you need to pace, some people describe it as “feeling like I am crawling out of my skin”); may repeat every 6 hours; do not exceed 80 mg in a day; hold for dizziness, sedation.

.rxPropranololAutonomicSymptoms
Propranolol 10 to 20 mg 2 to 3 times a day; if not effective, can increase by 10 to 10 mg per day not to exceed total daily dose of 80 mg; hold for dizziness, sedation.

.rxPropranololPerformanceAnxiety
Propranolol 10 to 20 mg by mouth about 1 hour prior to performance.

.rxSildenafil
Sildenafil 50 mg 1 hour (range 0.5 to 4 hours) prior to sexual activity; maximum frequency of administration once daily.

.rxQuetiapine
Take 1 tablet (50 mg) orally daily at bedtime; if well-tolerated, can increase by 1 to 2 tablets per night to reach a target dose range that is between 3 tabs (150 mg) and 6 tabs (600 mg) daily at bedtime; hold for excess sedation, dizziness, cognitive impairment.

.rxTrazodoneInitial
Trazodone 25 mg to 50 mg at bedtime as needed for sleep; okay to increase by 25 mg per night if ineffective and well-tolerated; do not exceed 200 mg dose; hold for excess sedation,
cognitive impairment, orthostasis.

.rxValproicAcidDementia
Based on uncontrolled and retrospective studies, relatively low doses (e.g. 7-12 mg/kg per day) of valproic acid, with serum levels between 40 and 60 mcg/mL, are associated with improvements in agitation in some patients with dementia (Dolder, J Phar.m Prac 2012).

.rxVenlafaxine
Venlafaxine XR titration: 37.5mg each morning for 7 days, then 75mg each morning for 7 days, then 150mg each morning for 7 days, then 225mg each morning. Always take medication with food. Always take medication in the morning. Check blood pressure 3 days after beginning each new dose at 150 mg and greater and contact PCP immediately if blood pressure is elevated. Do not miss doses as this can result in a rapid withdrawal syndrome.

.rxVenlafaxineRapidTitration
Venlafaxine XR titration: 37.5mg each morning for 4 days, then 112.5 each morning for 4 days, then 150mg each morning for 4 days, then 225 mg each morning. Always take medication with food. Always take medication in the morning. Check blood pressure 3 days after beginning each new dose at 150 mg and greater and contact PCP immediately if blood pressure is elevated

.rxZiprasidone
Ziprasidone 40 mg twice a day or 80 mg at bedtime; on day 2 increase to 60 mg twice a day or 120 mg at bedtime; take with food.

S

.scale = scale
*All of the scales here are in the public domain.

.scaleAnxietyFear
https://dl.dropboxusercontent.com/u/94001596/Fear.pdf

.scaleAnxietyHamilton
https://dl.dropboxusercontent.com/u/94001596/HAM-A%20For%20Anxiety.pdf

.scaleAnxietyPanic
https://dl.dropboxusercontent.com/u/94001596/Panic.pdf

.scaleDepressionGeriatric
https://dl.dropboxusercontent.com/u/94001596/Geriatric%20Depression%20Scale.pdf

.scaleDepressionHamilton
https://dl.dropboxusercontent.com/u/94001596/HAM-D%20For%20Depression.pdf

.scalePsychiatricSatisfaction
https://dl.dropboxusercontent.com/u/94001596/PsychiatricSatisfaction.pdf

.scaleQualityOfLife
https://dl.dropboxusercontent.com/u/94001596/QualityOfLife.pdf

.scaleSideEffects
https://dl.dropboxusercontent.com/u/94001596/SideEffects.pdf

.scaleSleepinessEpworth
https://dl.dropboxusercontent.com/u/94001596/EpworthSleepiness.pdf

.scaleSleepQuality
https://dl.dropboxusercontent.com/u/94001596/SleepQuality.pdf

.screen = screening questions for medical and psychiatric conditions

.screenStimulantsCardiac
Denies family history of unexplained sudden death less than 30 years
Denies family history or personal history of heart disease.
Denies family history or personal history of chest pain,palpitations, or fainting during exertion.
Denies history of dizzines while exercising.
Denies family history or personal history of prolonged QT Syndrome.

T

.temp = Templates

.tempMSE
Current MSE:
On my mental status examination presently, the patient is alert, attentive, and grossly oriented to person, place, and time. Appearance: Calm, pupils not large, no lacrimation, no rhinorrhea, no goose flesh. Speech spontaneous and normal in volume, rate, and rhythm. Mood: OK. Affect: Full. Thought process: Linear associations, normal rate, logical. Thought content is devoid of suicidal, homicidal, violent, and delusional material. There are no evident hallucinations. Judgment is fair. Insight is fair. Recent and remote memory: Grossly intact. Language is intact. Fund of knowledge: Grossly intact.

.tempNeuroExam
NEURO: CN II-XII intact. PERRLA, EOMI, VF full to confrontation. Motor 5/5. Babinski down going bilat. FTN/HTS intact bilat, rep mvts intact UE and LE bilat. No pronator drift. Romberg-negative, posture and gait wnl.

.tempNoteFU
Psychiatry Note

Psychiatric medications:

Interval history:

ROS
Denies other psychopathology, suicidal or homicidal ideation, recent substance or alcohol abuse, medication changes or non-adherence, other acute psychosocial stressors.

Relevant psychiatric history:
Psychiatric hospitalizations
Suicide attempts:
Substance use disorders:
Legal history:
Medical history:
Psychiatric history to substantiate the working diagnosis:

Mental Status Exam
On my mental status examination presently, the patient is alert, attentive, and grossly oriented to person, place, and time. Appearance: Well-groomed; dress appropriate to season and place. Speech spontaneous and normal in volume, rate, and rhythm. Mood: OK. Affect: Full. Thought process: Linear associations, normal rate, logical. Thought content is devoid of suicidal, homicidal, violent, and delusional material. There are no evident hallucinations. Judgment is fair. Insight is fair. Recent and remote memory: Grossly intact. Language is intact. Fund of knowledge: Grossly intact.

AIMS: negative for abnormal movements

I-STOP (or other prescription monitoring program): N/A

Relevant Labs:

Assessment:

Safety risk is increased overall given multiple dynamic and static risk factors mitigated by protective factors, as documented above and/or in initial assessment. There was no indication of currently increased or imminent danger to self or others based on today's exam; outpatient care with close monitoring is appropriate.

Plan:

Continue with safety/communication plan targeting dynamic risk factors

.tempNoteIntake
Adult Psychopharmacology Intake

@NAME@ is an @AGE@ , @SEX@, referred by … for evaluation and treatment.

Patient's Rights, confidentiality and exceptions to confidentiality, use of automated medical record, Behavioral Health Services staff access to medical record, and consent to treatment reviewed.

HPI

ROS:

Past Psychiatric History:
Life-time psychiatric hospitalizations:

Prior medication trials:

Suicide attempts: as per HPI

Violence history:

Other psychiatric disorders:
Eating disorders: none
Anxiety disorders: none
Psychosis: no clear history
Mania: no clear history
Depression: as per HPI
Self-injurious behaviors: no clear history

Substance Use History:
No IVDA
Alcohol /Benzodiazepines: no problematic use; SASQ negative
Cannabis: none
Cocaine and stimulants: none
Opiates: none
LSD and hallucinogens: none
Club drugs: none

Tobacco use:
Caffeine: cups per day

Past Medical/Surgical History:

Head trauma/LOC: none
Seizures: none
Brain infection: none

Current Psychiatric Medications:

Other Medications:

OTC Medications/Supplements:

Allergies:

Family Psychiatric History:

Social History:

Abuse History:

Legal History:

Current MSE: On my mental status examination presently, the patient is alert, attentive, and grossly oriented to person, place, and time. Appearance: Calm, pupils not large, no lacrimation, no rhinorrhea, no goose flesh. Speech spontaneous and normal in volume, rate, and rhythm. Mood: OK. Affect: Full. Thought process: Linear associations, normal rate, logical. Thought content is devoid of suicidal, homicidal, violent, and delusional material. There are no evident hallucinations. Judgment is fair. Insight is fair. Recent and remote memory: Grossly intact. Language is intact. Fund of knowledge: Grossly intact.

Studies:
Laboratory Data: n/a
Brain Imaging: n/a
Electrophysiology: n/a
Neuropsychiatric assessment: n/a

Impression:
x…
Suicide risk is increased overall given multiple dynamic (symptoms and stressors above (clinicians - please input specific symptoms and stressors) and static (***) risk factors mitigated by protective factors, including strong future-orientation, hopefulness, engagement with treatment, close relationships. Homicide Risk: low. There was no indication of currently increased or imminent danger to self or others based on today's exam; outpatient care with close monitoring is appropriate.

Recommendations:

Diagnostic Issues
1)
2)

Medications
1) x...
2) Informed consent disclosed for ; discussed ; noncompliance/abuse discussed. Warned.

Non-pharmacological treatments
1)

Safety
1) Safety/communication plan established targeting dynamic risk factors above.

Educational Materials:
1)

*Note adapted with permission from Dr. Oliver Freudenreich, MGH

.tempPastRx
Medication Trials:
-Antidepressants:
-Anxiolytics:
-Antipsychotics:
-Mood stabilizers

.tempRosETOHNeg
Denies blackouts, history of withdrawal, other functional or medical sequelae.

.tempRosNeuro
Denies other neurological symptoms, including changes in vision, headache, motor weakness, changes in sensation, censorium.

.tempRosPsych
Denies other psychopathology, suicidal or homicidal ideation, recent substance or alcohol abuse, medication changes or non-adherence, other acute psychosocial stressors.