Dr. Erman is clinical professor in the Department of Psychiatry at the University of California, San Diego School of Medicine, a staff scientist for the Scripps Research Institute Department of Neuropharmacology, and chief medical officer of Avastra USA.

Disclosures: Dr. Erman is a consultant to Cephalon, Mallinckrodt, Neurocrine, sanofi-aventis, and Takeda; is on the speaker’s bureaus of Forest, sanofi-aventis, and Takeda; is on the advisory boards of Cephalon, Neurocrine, sanofi-aventis, and Takeda; has received grant/research support from Arena, Cephalon, Eli Lilly, GlaxoSmithKline, Mallinckrodt, Merck, Organon, Pfizer, Pharmacia, ResMed, sanofi-aventis, Schwarz Pharma, and Takeda; and owns stock in Cephalon, Forest, Merck, Neurocrine, Pfizer, sanofi-aventis, and Sepracor.



From ghoulies and ghosties
And long-leggedy beasties
And things that go bump in the night,
Good Lord, deliver us!
       –Traditional Scottish Prayer


70-year-old female patient is screaming out at night. This has been going on for several decades but has been getting worse lately and is disturbing her husband’s sleep. She also has Parkinson’s disease, but this has only been present for approximately 10 years. Is this a sleep disorder? What stage of sleep is it likely occurring from?

Ancient history denotes the nighttime hours as a period of risk and uncertainty. It was believed that the soul left the body during people’s usual nightly episodes of sleep, and prayers for the safe return of the soul are common in numerous cultures. Abnormal behaviors occurring as one came out of sleep were also appreciated yet feared and misunderstood. Common knowledge “recognized” that a sleep walker should not be awakened for fear that he or she will die or be harmed; in more extreme forms of behavior, it was assumed that demonic possession was the cause of disturbed dreams or abnormal behaviors.

Most parasomnias, which are disorders associated with the occurrence of sleep but not necessarily disruptive of sleep itself, present in childhood and are seen with decreasing frequency as people age. Examples of such phenomena are enuresis (ie, bed-wetting), nightmares (ie, “rapid eye movement [REM] anxiety dreams”), sleep walking, sleep talking, and sleep terrors (ie, “night terrors”). A hereditary basis has been demonstrated for most of these disorders, and a strong family history is usually reported when parents or other family members are questioned.

Stress may be a contributing factor to the presentation of parasomnias or may increase their severity, but most of these disorders are not suggestive of the presence of any mental disease or condition. Patients with nightmares may at times be an exception to this statement. Particularly in adult life, the presence of anxious dreams, especially those with recurrent, violent content, may be associated with anxiety disorders or conditions such as posttraumatic stress disorder.

Most frequently, sleep deprivation, which may increase the intensity of deep non-dreaming (delta) sleep, is a factor when such problems present in adolescence or adult life.

First described in 1986, REM sleep behavior disorder (RBD), like sleepwalking, is associated with complicated behaviors during sleep such as walking, running, singing, and talking.1 In contrast to sleepwalking, which occurs during the first third of the night during delta sleep, RBD usually occurs during the second half of the night during REM sleep.

In order to appreciate the pathophysiology of RBD, it is critical to understand the basic physiology of REM (dreaming) sleep. In REM sleep, the skeletal muscles associated with voluntary movements are paralyzed. This paralysis (ie, atonia) is seen in association with REM sleep in all mammalian species that have been studied and appears to be an integral component of dream sleep.

Why should this paralysis of the voluntary musculature be a “desirable” or necessary component of REM? To the dreamer, the world experienced in the dream is reality. If, in one’s dream, he or she is walking down the street, the voluntary muscles would receive innervation that would accomplish this task. Such activity would be disruptive of the capacity to maintain continuity of dreaming sleep and could be dangerous to the “enacted” dreamer as well.

Prior to the initial description of RBD, animal research demonstrated that the normal atonia of REM sleep could be disrupted as a consequence of specific brain lesions. In 1965, Jouvet and colleagues,2 in France, performed bilateral lesions in the midbrain (ie, “pons”) of cats, blocking the normal inhibition of muscle tone seen in REM sleep. These animals showed prominent, and apparently purposeful, motor behavior in REM sleep. Although it is impossible to know with any certainty what, if anything, the cats were dreaming, the behaviors seen included apparent predation (eg, act of trapping a mouse or other prey with a paw or swiping at and pouncing on an unseen object.)

 RBD, the human version of that disorder, apparently occurs as a consequence of loss of the muscle atonia that is normally present during REM sleep (although intermittent throughout the night), facilitating enacted dream motor activity. The intensity of motor activity may vary and usually increases in severity with passage of time and progression of the disease. Initial manifestations may be of sleep talking or mumbling, often associated with small motor activity. The movement activity that occurs often appears purposeful or semi-purposeful. Direct examples include patients appearing to be scolding someone and shaking their finger at them; cutting food with a fork and knife and moving it to their mouth to eat; folding objects (eg, clothes); and engaging in sports (eg, fly-fishing). Verbal outbursts may sound angry and include vulgarity or obscenities never uttered by these quiet individuals during their waking hours.

In contrast to history typically obtained from patients with sleepwalking or other non-REM arousal disorders, memory for dream content is usually good in patients with RBD when they are questioned after arousal from an RBD episode. They are usually able to describe what was occurring in their dream and what they were attempting to accomplish, which led to their enacted dream activity. Even when dream content is neutral or pleasant, patients or their bed partners may be at risk of injury as a result of this motor activity occurring out of REM sleep. For example, patients have injured themselves by throwing themselves out of bed in association with dreams of sports activities, including chasing a long fly ball and running down field to catch a pass in football.

Patients with RBD frequently experience frightening or threatening dream content that may provoke a “defensive” response on their part, putting bed-partners at risk. For example, if a patient is fighting a wild animal, assailant, or someone trying to steal his or her car or kidnap a family member in a dream, the individual may be choking, punching, or otherwise assaulting his or her spouse or bed partner in reality.

In contrast to non-REM parasomnias that usually present in childhood, RBD typically occurs in men during the sixth or seventh decade of life. The cause or causes remain unknown. The current understanding of this disorder’s etiology is that it is usually idiopathic, though it may be seen in association with neurodegenerative disorders (ie, Parkinson’s disease, olivopontocerebellar degeneration, Shy-Drager syndrome, dementia with Lewy body disease).3 RBD is often the first manifestation of these conditions, and it may precede any other neurologic symptoms by >10 years.4

Although a clear long-term causal relationship has not been established, apparent medication-induced loss of REM atonia has been observed in patients receiving tricyclic antidepressants5 and selective serotonin reuptake inhibitors.6

Diagnosis of RBD is often delayed for years or decades, as physicians assessing the patient may be unaware of the existence of the disorder. The diagnosis may be suspected on clinical grounds, especially when “atypical” nocturnal behavior, including vocalization, semi-purposeful motor activities, or apparent assaults of a bed partner, occurs in individuals with no apparent behavioral or emotional difficulties seen during the daytime. When possible, the diagnosis should be confirmed by polysomnographic (PSG) evaluation. In addition to the intermittent absence of atonia, PSG findings include bursts of increased muscle tone seen on EMG and limb twitching (usually far greater than what is seen in normal REM sleep) and complex, at times violent, behavior associated with reported dream imagery. PSG also allows the opportunity to rule out the co-existence of other sleep disorders that could provoke episodes of RBD, such as sleep apnea, and to ensure that the behavior seen is not an epileptiform disorder.
Treatment of RBD usually includes nocturnal administration of clonazepam, typically in a dose of 0.5–1.5 mg, though some patients require doses of up to 3–4 mg for effective treatment. Treatment with clonazepam is often remarkably successful in controlling the symptoms of this disorder, although the mode of therapeutic effect of the agent is not known.

Antidepressants may have the capacity to provoke or exacerbate the severity of RBD. When patients are taking these medications, efforts should be made to reduce the dose of or eventually discontinue treatment when possible.

Limited studies, typically performing open-label trials in small case series, suggest that melatonin in doses of 3–12 mg at night may be effective for some patients who have not responded to treatment with clonazepam.7 PP



1. Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep. 1986;9(2):293-308.
2. Dusan-Peyrethon D, Peyrethon J, Jouvet M. Quantitative study of phasic phenomena of paradoxal sleep during and after its instrumental deprivation [French]. C R Seances Soc Biol Fil. 1967;161(12):2530-2533
3. Boeve BF, Silber MH, Ferman TJ, Lucas JA, Parisi JE. Association of REM sleep behavior disorder and neurodegenerative disease may reflect an underlying synucleinopathy. Mov Disord. 2001;16(4):622-630.
4. Schenck CH, Mahowald MW. Rapid eye movement sleep parasomnias. Neurol Clin. 2005;23(4):1107-1126.
5. Shimizu T, Ookawa M, Iijuma S, et al. Effect of clomipramine on nocturnal sleep of normal human subjects. Annu Rev Pharmacopsychiat Res Found. 1985;16:138.
6. Schenck CH, Mahowald MW, Kim SW, O’Connor KA, Hurwitz TD. Prominent eye movements during NREM sleep and REM sleep behavior disorder associated with fluoxetine treatment of depression and obsessive-compulsive disorder. Sleep. 1992;15(3): 226-235.
7. Takeuchi N, Uchimura N, Hashizume Y, et al. Melatonin therapy for REM sleep behavior disorder. Psychiatry Clin Neurosci. 2001;55(3):267-269.

Psychiatric Dispatches

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Primary Psychiatry. 2008;15(7):24-26

FDA Approves Duloxetine HCI for the Management of Fibromyalgia

The United States Food and Drug Administration approved duloxetine HCI (Cymbalta, Eli Lilly) for the management of fibromyalgia. Fibromyalgia is estimated to affect 2% of the United States population, with the majority of diagnoses being made in women.

Approval was based on the results of two 3-month clinical trials representing 874 patients with fibromyalgia. In week 1 of both studies, the duloxetine group demonstrated significant improvement in pain compared to placebo, according to the Brief Pain Inventory (BPI), a 24-hour average pain scale. Fifty-one percent and 55% of patients on duloxetine of the two respective studies experienced a 30% improvement (the threshold for clinical pain improvement) on the BPI by endpoint. Also, at both trials’ endpoint, 65% and 66% of patients on duloxetine 60 mg/day reported overall symptomatic improvement according to the Patient Global Impression of Improvement scores.

The most common adverse events associated with duloxetine include nausea, dry mouth, constipation, decreased appetite, sleepiness, increased sweating, and agitation.

For more information, please consult the medication’s full  prescribing information. (www.insidecymbalta.com). —LS


Acute Stress Disorder and PTSD Diagnoses May Predict Future Onset of Chronic PTSD

Survival after a major burn injury has substantially improved over the past 20 years. However, there is evidence of psychological distress and disorders following this type of injury, including acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). A study by Jodi B. A. McKibben, PhD, and colleagues, considered whether an ASD diagnosis, with its dissociative symptoms, is a better predictor of chronic PTSD than a PTSD diagnosis made at the same time in a major burn population.

The study involved 178 hospitalized adult patients (73.6% male; 23.4% female) with major burns treated at Johns Hopkins Burn Center. Scores from self-report measures, including the Stanford Acute Stress Reaction Questionnaire (SASRQ), Davidson Trauma Scale (DTS), and Brief Symptom Inventory, were used to determine biopsychosocial function at five time periods. In accordance with criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the SASRQ assessed ASD and PTSD at discharge from the center (n=178) while the DTS assessed PTSD at 1 (n=151), 6 (n=111), 12 (n=105), and 24 (n=71) months after discharge. Results found that both ASD and PTSD diagnoses at discharge were major indicators of future onset of PTSD at 1, 6, and 12 months, but not at 24 months, with no significant differences in predictive ability at any time. 

McKibben and colleagues suggest future research to measure all ASD and PTSD criteria at discharge, as the current study neglected to assess two PTSD avoidance criteria (ie, decreased interested/participation and sense of limited future). In addition, structured interviews assessing ASD and PTSD as well as efforts to reduce attrition rates in burn populations from other hospitals would further validate and address the generalizability of results. (APA 2008; Poster NR 6-069). –ML


Parents With Bipolar Disorder at Increased Risk for Substance Use Disorders Than Healthy Parents

According to the National Institute of Mental Health, bipolar disorder is often comorbid with substance use disorders, which may be caused by bipolar mood symptoms often exacerbated by alcohol and drug use, a patient’s intent to self-medicate symptoms, and other risk factors related to both bipolar disorder and substance abuse. Research has shown that substance use disorder risk is increased among parents of youths with bipolar disorder, particularly if parents also have bipolar disorder.

However, there have been few studies that investigate the prevalence of substance use disorders among parents with bipolar disorder, separate from the mental health status of the child. The prevalence of substance use disorders may be useful for clinicians, as parental substance use has been shown to increase the risk of child maltreatment and impairment.

Benjamin I. Goldstein, MD, PhD, of the Western Psychiatric Institute and Clinic at the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues, evaluated 448 adult parents with and without bipolar disorder to determine rates of substance use disorder prevalence. Patients were divided by bipolar disorder symptomology (n=274: Type I, n=175; Type II, n=83; not otherwise specified, n=16) or presence of other psychiatric conditions (n=112), and were compared to participants without mental health disorder history (n=62).

Patients were assessed for bipolar disorder via the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID-IV). All children of parents in the study were ≤18 years of age, and 79% of parents were female. Other patient demographic and clinical information regarding substance use was assessed by researchers via interview at the study’s beginning. Demographic variables significantly associated with lifetime prevalence of substance use disorder were included in analysis.

Goldstein and colleagues found that substance use disorders were significantly more prevalent for patients with bipolar disorder (64%) when compared to patients with other psychiatric disorders (40%) or parents without bipolar disorder (21%). This result remained after the authors controlled for between-group differences in socioeconomic and marital status as well as race. When compared to healthy parents with substance use disorders, patients with bipolar disorder showed significantly greater prevalence of alcohol abuse (59% vs. 31%), and cocaine (22% vs. 8%) and opioid (7% vs. 0%) dependence.

In addition, the presence of a substance use disorder in one parent was significantly associated with the development of a substance use disorder in another parent despite bipolar disorder prevalence. Goldstein and colleagues concluded that parents with bipolar disorder are at a greatly increased risk for developing substance use disorders, which may confer genetic and environmental risk of negative outcome for the child.

“It is important for primary care phyisicans (PCPs) who work with families to know that parents with bipolar disorder have increased likelihood of having substance use disorders, and there is also increased likelihood of substance abuse in the other parent. Careful screening for excessive drug or alcohol use is warranted, and PCPs should encourage parents to seek specific treatment for substance abuse ideally in a manner that is integrated with their treatment for bipolar disorder,” Dr. Goldstein said. “Previous studies have found that children of parents who abuse substances are exposed to two-fold increased risk of maltreatment, and the risk is greater when both parents abuse substances. The hope is that early identification of parental substance use disorders and referral for appropriate treatment may decrease this risk to children.”

The authors recommend researchers conduct long-term, prospective studies that examine the potential role of parental substance abuse in relation to mental health and behavioral outcomes for children in the future. Study limitations include the cross-sectional study design and retrospective methodology as well as the lack of a dimensional measure of current substance abuse.

Funding for this research was provided by the National Institute of Mental Health. (APA 2008; Poster NR3-041). –CP


Risk Factors and Prevalence of Postpartum Depression

Postpartum depression (PPD) is a form of clinical depression that can affect women after childbirth and can even start toward the end of pregnancy. Often undiagnosed or untreated, the prevalence of PPD is estimated to be 12% to 13%. Risk factors include psychosocial variables such as marital dissatisfaction, inadequate social support, and stressful life events. Demographic variables include adolescent pregnancy, unwanted or unplanned pregnancy, and lower socioeconomic status. Psychiatric family and personal history can also prove to be risk factors as well. Early intervention of PPD is ideal as the disorder can negatively affect both mother and infant.

A study by Nesrin Tomruk, MD, and colleagues, at Bakirköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery in Istanbul, Turkey, examined postpartum patients in the well-baby unit in up to 9 months postpartum period from July–September 2007 and screened for depressive symptoms using the Edinburgh Postnatal Demographic Depression Scale (EPDS). The cut-off point of the 10-item self-rated questionnaire was ≥13; patients with scores ≥13 were labeled as “high risk for depressive disorder.” Demographic and psychosocial variables as well as reproductive, pregnancy, and delivery data were also collected using a separate 51-item semi-structured form.

According to EPDS scores, PPD was found in 30.6% (n=56) of the 183 mothers in the study (mean age=27.52±5.45). High EPDS scores were also significantly correlated with history of premenstrual syndrome and psychiatric treatment as well as the partner’s unemployment, dissatisfaction in marriage, low level of care of the partner, and domestic violence. Also of statistical significance, high EPDS scores were correlated with unplanned pregnancies, nocturnal delivery, health problems during pregnancy in both the mother and fetus, a “difficult baby,” and not nursing.

The study is limited in that the EPDS, when used alone, is not a diagnostic tool for depression. Depression diagnosis should be verified with clinical evaluation as well as other depression scales. However, the EPDS is useful for screening pregnant and postpartum women for early detection and treatment of PPD. (APA 2008; Poster NR 6-120). –DC


HIV Patients with Comorbid Psychiatric Disorders

Previous research has found that patients who are HIV positive (HIV+) have high rates of both substance abuse as well as psychiatric disorders. However, exact prevalence rates have been hard to determine due to patient non-adherence. Rachel A Houchins, MD, and colleagues from the University of South Carolina of Medicine and Palmetto Health Alliance conducted a chart review of 424 HIV+ patients. They collected data regarding age, gender, race, medical conditions, psychiatric diagnoses, substance abuse, income, medications, CD4 count, and viral load of patients seen at the Ryan White Clinic between 2004 and 2006.

Houchins and colleagues found that 41.3% of patients were substance abusers; 35.4% of patients had psychiatric illnesses; 24.9% of patients had a diagnosis of substance abuse; 19% of patients had a psychiatric diagnosis only; and 16.4% of patients had a comorbid diagnosis. However, the rates changed depending on gender and race. They also recorded data regarding patient compliance in terms of medication as well as their ability to keep appointments.

Houchins and colleagues found that a total of 39.7% of patients had no Axis-I diagnosis, 24.9% of all patients had a diagnosis of substance abuse only, 19% had a psychiatric diagnosis only, and 16.4% had comorbidities. When breaking this data down by gender, they found that 72.4% of men were substance abusers only compared to 26.4% of women, while psychiatric diagnosis only was more evenly split (50.6% for men vs 48.2% for women).

When comparing race, 92.5% of blacks were substance abusers only and 70.4% of blacks had a psychiatric diagnosis only Approximately 51% of men had a psychiatric diagnosis only, compared to approximately 48% of women. Comorbidities were more evenly dispersed among gender and ethnicity. They found that 61.4% of men, 38.6% of women, 74.3% of blacks, and 25.7% of whites had comorbidities. Surprisingly, they also found that compliance rates were not statistically different among any of the demographics. In addition, there was no correlation between medical compliance and CD4 counts.

Houchins and colleagues believe that future research should detail the means of engaging the patient in treatment and teach them the means of appropriately participating in their own health care. (APA 2008; Poster NR 1-009).  —CN


Threshold Treatment Levels for Functional Improvement in ADHD

Successful long-term outcomes in clinical trials of attention-deficit/hyperactivity disorder (ADHD) treatment have been associated with less severe symptoms at baseline. Conversely, greater symptom severity at baseline can lead to a poorer prognosis. It is less clear, however, to what extent reductions in ADHD symptoms correlate with improved life functioning, as well as what level of treatment is necessary to facilitate functional improvements.

A meta-analysis by Buitelaar and colleagues identified four studies that included a symptomatic measure (ADHD Rating Scale-IV:Parent-Inv [ADHD RS]) and a functional measure (Life Participation Scale [LPS]). The ADHD RS is an 18-item, clinically administered scale that rates the severity of ADHD symptoms with scores ranging from 0–54, with lower scores indicating less symptoms. The LPS, a 24 item scale, measures functional improvements related to treatment with scores from 0–72, with 72 indicating the most improvement.

Subjects, males and females 6–18 years of age at baseline, included those in an atomoxetine group (N=564), methylphenidate (N=220), and placebo (N=256). The mean age of all three groups combined was 10.3 years, and the majority of subjects were diagnosed with ADHD combined type.

Changes in LPS scores over the study’s duration were standardized by calculating the difference between each subject’s change score and the mean of all change LPS scores from all subjects, divided by the standard deviation (SD) of the changes from all subjects. Those with a standardized change of <0.25 SD were defined as indicating no change in functioning, but changes in score >1.0 SD indicated significant functional improvement or worsening. Changes 0.25 SD–1.0 SD indicated a threshold change.

Mean changes in ADHD RS scores were compared with corresponding changes in LPS scores. Buitelaar and colleagues found that a reduction of 16–18 points on the ADHD RS is required for threshold functional improvement, which translates to a 40% to 45% improvement in symptom severity.

A significant improvement in functioning, ie, LPS changes >1.0 SD, requires an ADHD RS score reduction of 20–27 points, which corresponds with 50% to 65% improvement. Overall, an ADHD RS score reduction of at least 20 points is necessary for patients to demonstrate significant improvements in functioning. (APA 2008; Poster NR6-016). –LS

Posters were drawn from the 161st Annual Meeting of the American Psychiatric Association (APA; May 3–8, Washington, DC). Psychiatric dispatches is written by Dena Croog, Michelisa Lanche, Christopher Naccari, Carlos Perkins, Jr, and Lonnie Stoltzfoos.


This interview took place on April 29, 2008, and was conducted by Norman Sussman, MD.


This interview is also available as an audio PsychCastTM at http://psychcast.mblcommunications.com.

Disclosure: Dr. Allen reports no affiliation with or financial interest in any organization that may pose a conflict of interest.


Dr. Allen is both assistant professor in the Department of Psychiatry at the Mount Sinai School of Medicine (MSSM) in New York City and director of psychological services at MSSM’s Center of Excellence in Compulsive and Impulsive Disorders. Her research interests primarily include the treatment of disorders within the obsessive-compulsive spectrum, including obsessive-compulsive disorder and body dysmorphic disorder. In addition, she trains psychiatrists and psychologists on these conditions. Dr. Allen is a widely published author of numerous original research publications and review articles.


What are the basic principles upon which cognitive-behavioral therapy (CBT) is based?

CBT refers to a general approach to therapy that includes many different therapies (eg, behavior therapy, cognitive therapy, dialectical behavior therapy, rational emotive therapy) that share the same general philosophy and basic principles. These therapies focus on relieving current symptoms. CBT is an active, directive therapy wherein a therapist acts as a patient’s coach and collaborates with the patient to determine the goals of treatment and the process. The work outside the sessions is an important part of these therapies. There is a big focus on applying what is learned during sessions to the patient’s life. CBT tends to be very evidence based.

One of the most basic assumptions these therapies share is that emotional reactions come from our interpretations of events, not from the events themselves. An ordinary event can seem like a catastrophe to people with obsessive-compulsive disorder (OCD) because of how they are interpreting it. For example, if someone touches a patient with OCD, this action could cause the patient to internally panic. The patient may feel contaminated and be concerned about bringing this contamination home to his or her children, exposing them to serious illnesses. In this example, CBT would focus on identifying, challenging, and modifying the OCD patient’s faulty beliefs and reasoning.

Basic learning principles underlie the behavioral techniques. When they are applied to OCD, the learning principles would predict that the compulsive rituals and avoidance associated with OCD increase a patient’s fears and reinforce his or her obsessions. For example, an OCD patient who repeatedly checks the stove to confirm that it is turned off feels relieved by that checking. According to learning theory, this relief is reinforcing and increases the patient’s need to check. Taking part in these rituals or avoiding uncomfortable circumstances prevents the fear from subsiding; that is, if the person could resist checking the stove, his or her anxiety would end.


Is there empirical evidence showing the effectiveness of CBT for the treatment of OCD?

Most studies concerning CBT for OCD focused on the major components of CBT, specifically exposure and response prevention and cognitive therapy. In the studies of exposure and response prevention, the participants are placed in a situation that provokes their OCD and they resist the ritual or the response they feel compelled to perform. Empirical evidence is provided by multiple randomized clinical trials1-4 in which exposure and response prevention outperforms an active treatment control. In general, these trials cannot be double blind as the therapist and patient know which treatment is used. However, there have been trials5,6 comparing exposure and response prevention conducted by a therapist versus by a computer (with the patient also using written self-help materials) that show exposure and response prevention is more effective than placebo or control treatments in reducing OCD symptoms.

The most powerful evidence for the efficacy of exposure and response prevention comes from brain imaging research during the early 1990s. Studies7,8 using positron emission tomography scans prior to and following treatment showed that exposure and response prevention as well as serotonin reuptake inhibitors normalize brain activity.

In terms of the cognitive approach, correcting the patient’s cognitive errors and faulty reasoning is the primary focus. There is evidence from several randomized controlled trials9-12 showing that cognitive approaches are as effective as exposure and response prevention in certain ways and definitely more effective than control treatments. However, the studies showing cognitive therapy to be as effective as exposure and response prevention include behavioral experiments. In these experiments, the patients participate in brief exposures to test the validity of their fears, that is, to see if the feared consequences occur. The major difference between exposure and response prevention and cognitive therapy in these trials is that the exposures were shorter in length in the cognitive therapy conditions. In addition, it is not clear what other kinds of exposures the patients may have faced during the studies, so whether cognitive therapy is effective without exposures is still debatable. At this point, it is unclear that exposure and response prevention is not the central or most powerful curative element in OCD.

Cognitive therapy research indicates that the main drawback to exposure and response prevention is that some patients will avoid such therapy altogether or will drop out of it because they find the very idea of the exposures too scary. I think it is important to consider that perhaps exposures do not need to be as long as we had believed in order to be effective. In reality, most cognitive-behavioral therapists use both exposures and cognitive techniques. Teasing apart the contributions of each might not have that much of an impact on the treatment in the real world.


What is relaxation training?

It is a part of CBT that is frequently used, but it is not an effective monotherapy for OCD. However, OCD symptoms are often exacerbated by stress; therefore, relaxation and stress management is part of the treatment. For patients who have a terrible time tolerating anxiety and a phobia of the anxiety itself, decatastrophizing anxiety and helping them learn to be less anxious is imperative.

Relaxation training usually has two elements, ie, deep breathing and muscle relaxation. Deep breathing techniques are taught in sessions and practiced out of session. After patients learn it, they can apply it in stressful situations, possibly reducing the autonomic elements of stress. Progressive muscle relaxation techniques ordinarily include having the patient listen to a 10–30-minute long tape that gets him or her to relax each muscle group, starting with the toes. The goal is to have patients learn what relaxed muscles feel like while following the tape and be able to relax them in the real world when they feel stressed. The more patients practice and perform these techniques, the more relaxed they can become.

Some patients with OCD will get extremely anxious (eg, sweat, have palpitations) when they are in situations that provoke their OCD fears. For example, a patient of mine with contamination fears had a lot of trouble at work when colleagues would pat him on the back. Since he could not avoid this or immediately leave and wash his clothing, it was helpful for him to learn relaxation techniques to help him to control his anxiety in these situations. He learned deep breathing, so as soon as he started to feel symptoms of anxiety he would take a few deep breaths. This often turned the situation around and enabled him to stay and behave appropriately. Relaxation training is not going to cure the disorder, but it can make unavoidable situations more manageable. Training patients to be aware of their anxiety early is key. If they wait until they are already panicking, then the techniques are not as effective.


Does CBT help people realize that their symptoms result from the illness?

Yes. Most patients with OCD have fairly good insight. However, when they are faced with a scary situation, a contamination situation, or a situation wherein they think they did not turn off the stove, they might lose their insight in those moments and think there is real danger. If patients completely lack insight, it presents real problems in treatment, but it is more likely for insight to be a problem in OCD situations.

It is very valuable for patients both to know that their symptoms result from OCD and to be able to identify the specific thoughts and behaviors related to the disorder. Some patients might not know about OCD; they may think they are going crazy. When a clinician educates the patient about OCD, it can be reassuring to find out what the problem is and that there is a name and treatment for it. In addition, I typically use a cognitive assignment wherein people label their OCD thoughts and behaviors to help them become aware of when their thoughts and behaviors are an expression of their OCD. Over time, labeling helps patients with OCD to recognize that a thought or behavior is OCD rather than a realistic concern or reaction, ultimately helping them to be less upset by their intrusive thoughts and to resist performing their rituals.


Do symptoms get worse during the course of treatment as the patient attempts to alter behavior or thoughts?

When patients are in CBT, the exposure and response prevention exercises will be more stressful than the same situation would be if the patient just went ahead and performed an OCD ritual; that is to be expected and the patients should be educated to understand that. However, trying to do too much too quickly can be a problem. It is important to make sure that the exposures are not too stressful for the patient. The goal is for the exposures to be tolerable, to increase anxiety but not so much that the patient will resort to a ritual to reduce his or her anxiety; this is considered necessary for exposure and response prevention to succeed in reducing OCD symptoms. An exposure can backfire if it is too severe because the patient can get extremely upset, lose confidence in the technique, or even leave therapy. Having patients work on too many things simultaneously can also be a problem; a realistic plan of action should be created. If a patient tries to stop performing many rituals at the same time, the patient’s likelihood of success is lowered. For example, when a person decides to go to the gym every morning before work to get in better shape, he or she most likely will not stick to that plan. A more realistic exercise plan would have a better chance of being carried out.

Sometimes, symptoms will worsen during a fairly typical treatment. For example, the patient may have successfully reduced his or her checking the stove as part of an assignment but may find he or she is checking something else such as the windows to make sure they are locked. This situation does not usually create a problem, despite the worsening symptoms. Once they realize that another symptom is increasing, patients can usually reduce the behavior back to the baseline level and keep it there; if not, the increased symptoms can be specifically targeted in therapy. In my experience, a significant worsening in symptoms that cannot be easily reversed is usually due to one of three factors. First, another stressor could be increasing the OCD in general. Second, the patient could be completing assignments incorrectly and inadvertently reinforcing the OCD. Third, the patient may be at a major point of improvement and is getting anxious about that.


Is there a specific time course for treatment with CBT?

It is reasonable to expect to see improvement in as early as 3–4 weeks. If the patient is completing the assignments and the exposures, then he or she is going to benefit from therapy. Whenever a patient cannot complete an assignment, the patient and the therapist need to trouble shoot to figure out what might be interfering. If the patient is still not able to complete assignments after the first 3–4 weeks, the therapist has to consider the problem and discuss it with the patient in terms of possible treatment options. For example, it is possible that a medication could help the patient tolerate exposures. If a patient does not want to go on medication, the therapist can negotiate with him or her. The therapist could suggest that the patient try the exposures without medication for a few more weeks, but if the patient is still not able to do the exposures within that time period then medication will become part of treatment. That may motivate the patient to do the exposures.

Certainly after 6–8 weeks patients should notice that they can manage specific situations better, though they may not feel that the disorder is markedly improved. Results show quickly, but most studies are conducted within 12 weeks, which is not adequate time for treatment in most OCD cases. A clinically meaningful response will be found in that period of time, but there will be many residual symptoms. In private practice, I would generally recommend much longer treatment in order to do a better job of getting rid of symptoms.


How would the importance of consistent reinforcement versus intermittent reinforcement impact the treatment negatively or positively?

I think consistency is very important. There is a long line of basic learning research13 that shows things learned with random, intermittent reinforcement are very difficult to extinguish. For example, in some research conducted using rats, the researchers would train rats to press a lever to get a piece of kibble. Using continual reinforcement, the rat would get a piece every time they pressed the lever. Using random, intermittent reinforcement, the rats receive a piece of kibble unpredictably; the outcome of pressing the lever is unpredictable. Other rats might be given kibble consistently, say every tenth time the lever was pressed. When the researchers stopped feeding them, the rats that were fed on the random intermittent reinforcement schedule continued to press the lever for food for much longer than rats in any of the other conditions; the rats that were fed every time they pressed the lever stopped pressing the quickest. The lever pressing behavior was much more difficult to extinguish in the random, intermittently fed rats.

In OCD, the concept of intermittent reinforcement can easily be applied to reassurance seeking. OCD patients will often ask their families for reassurance (eg, whether something is contaminated), and families will reassure them to calm them, thus unknowingly reinforcing the OCD. If families realize this is reinforcing the disorder, they may attempt to stop it. However, they are often inconsistent in doing so. For example, patients may beg their families for reassurance and the families may occasionally give in and provide this reassurance. Based on learning theory, this is going to make patients continue to seek reassurance and it will be even more difficult to extinguish than if they had kept reassuring them continuously. That is, OCD patients will continue to ask for reassurance because it succeeds; they get the reassurance and it calms them for the moment. Importantly, not getting reassurance on a particular occasion will just make them ask more because they have learned that they will get reassurance eventually.

In addition, since the families are most likely to give in when the patient is upset and out of control, the patient’s more extreme behavior is selectively reinforced. Not only is the patient going to continue to ask for reassurance, but the intensity of the requests will increase since that is what is being reinforced and that is what persuades the family.

This can also be applied to situations in which a patient tries to resist performing rituals. The patient will resist until he or she cannot take it anymore. When the individual can no longer take it, he or she will give in to the urges and perform the behavioral rituals. The OCD urges are reinforced intermittently. However, there is a pattern—the more intense a patient’s OCD distress, the more likely he or she is to give in and perform the ritual, so the OCD is strongly reinforced. This is common among patients who try to apply CBT on their own. Numerous patients believe that CBT does not work based on their efforts to stop their rituals on their own. However, that is only because they intermittently reinforced the disorder.

It is common for OCD patients to seek reassurance from their clinicians and it is important for the clinicians to avoid reinforcing their patients’ OCD. I usually tell obsessive patients that they cannot ask repeat questions during phone calls or therapy sessions. They can ask any question once, including matters concerning particular side effects or whether or not something is OCD or is really dangerous. An obsessive patient can be very repetitive, and this is harmful to them. If a patient asks a question once and repeats it, a therapist should remind him or her that the question has already been answered, but that is all that should be done. The patient should not get to ask that question anymore. In explaining that to the patient, I emphasize how repeating questions is not good for them, not that it is bothersome. I tell them that performing these rituals reinforces their OCD and that I cannot be complicit to worsening their condition. PP



1. Marks IM, Hodgson R, Rachman S. Treatment of chronic obsessive-compulsive neurosis by in-vivo exposure: a two-year follow-up and issues in treatment. Br J Psychiatry. 1975;127:349-364.
2. Roper G, Rachman S, Marks I. Passive and participant modelling in exposure treatment of obsessive-compulsive neurotics. Behav Res Ther. 1975;13(4):271-279.
3. Lindsay M, Crino R, Andrews G. Controlled trial of exposure and response prevention in obsessive-compulsive disorder. Br J Psychiatry. 1997;171:135-139.
4. Nakatani E, Nakagawa A, Nakao T, et al. A randomized controlled trial of Japanese patients with obsessive-compulsive disorder–effectiveness of behavior therapy and fluvoxamine. Psychother Psychosom. 2005;74(5):269-276.
5. Marks IM, Baer L, Greist JH, Park JM, et al. Home self-assessment of obsessive-compulsive disorder. Use of a manual and a computer-conducted telephone interview: two UK-US studies. Br J Psychiatry. 1998;172:406-412.
6. Greist JH, Marks IM, Baer L, et al. Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry. 2002;63(2):138-145.
7. Baxter LR Jr, Schwartz JM, Bergman KS, et al. Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Arch Gen Psychiatry. 1992;49(9):681-689.
8. Schwartz JM, Stoessel PW, Baxter LR Jr, Martin KM, Phelps ME. Systematic changes in cerebral glucose metabolic rate after successful behavior modification treatment of obsessive-compulsive disorder. Arch Gen Psychiatry. 1996;53(2):109-113.
9. van Oppen P, de Haan E, van Balkom AJ, Spinhoven P, Hoogduin K, van Dyck R. Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder. Behav Res Ther. 1995;33(4):379-390.
10. van Balkom AJ, de Haan E, van Oppen P, Spinhoven P, Hoogduin KA, van Dyck R. Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive compulsive disorder. J Nerv Ment Dis. 1998;186(8):492-499.
11. Cottraux J, Note I, Yao SN, et al. A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder. Psychother Psychosom. 2001;70(6):288-297.
12. Whittal ML, Thordarson DS, McLean PD. Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention. Behav Res Ther. 2005;43(12):1559-1576.
13. Skinner BF. The Behavior of Organisms: An Experimental Analysis. Oxford, England: Appleton-Century; 1938.

e-mail: ns@mblcommunications.com


Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.

Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.



Unlike most issues of Primary Psychiatry, the focus this month is on a specific clinical facility rather than particular diseases and treatments. In deciding to devote this issue to a discussion of the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) at the New York University (NYU) Langone Medical Center in New York City, it is hoped that many readers who are in a position to influence decisions and funding involving clinical services for children and young adults will use the SDHCC model to create similar programs in their communities. While all centers endeavor to provide excellent, state of the art medical care, sometimes sensibilities about environment in which services are provided can be left wanting.

Often, when dealing with life-threatening illnesses, so much emphasis is given to the medicine regimen or surgical interventions that resources are not provided psychosocial support. This can be due to lack of funding or the lack of priority given to non-essential infrastructure and services. In the case of the SDHCC, which treats children with cancers and blood disorders (including brain tumors, bone and soft tissue sarcomas, leukemia, vascular malformations and other diseases of the blood such as platelet and blood-clotting disorders), the reaction of patients, their families, and the staff strongly support the value of the comprehensiveness of services in one site and the emphasis of complementary interventions in improving the quality of life for these young patients. The staff is committed to providing compassionate care to both the physical and emotional needs of the pediatric patients and their families.

The SDHCC was named in memory of Stephen D. Hassenfeld, Chairman of Hasbro, Inc., the famous toy company. He was also founder of the Hasbro Children’s Foundation. The mission of the SDHCC is to provide the best possible research-driven care in a compassionate and respectful manner to all children in need regardless of financial ability.

Patients not only benefit from the results of nationally established protocols, but also have immediate access to original research pioneered by physicians in areas such as stem cell transplantation and interferon therapy.

Anyone, young or old, who has experienced a serious illness themselves or in a family member probably knows how frightening visits to the doctor, hospital, or laboratory can be. At its worst, the visits can be dehumanizing, as the patient sits in a waiting room reading old magazines, then goes into a windowless room for an examination or test. Most often one then needs to go to a separate lab for blood work. Typically, care and visits are not coordinated; patients and companions may be inconvenienced as visits may be spread out at several sites over several days. Apart from the uplifting decor and thoughtful use of space at the SDHCC, the various specialties utilize an integrated multi-disciplinary model to provide comprehensive and individualized care. A behavioral health team endeavors to facilitate normal development in spite of the serious illness and the impact of treatment as well as to enhance the patients’ and families’ ability to understand the illness and handle the many emotions that can accompany it.

As described at the center’s Web site:


Our psychiatrists, psychologists, social workers and child life specialists help children and family members recognize important and often confusing feelings that may be difficult to express. The team uses an array of specialty services including neuropsychological and educational evaluations for appropriate school placement; “medical play” to help children achieve a sense of mastery and control over their situation; creative arts therapies that allow for nonverbal expression of feelings; and individual and group counseling to teach coping strategies.1

The SDHCC has playroom space for play therapy activities, a video room for watching movies, and comfortable private room for treatments that take several hours. Having an on-site laboratory provides physicians with immediate results and streamlines appointment times.

This issue is not intended as a public relations piece for the SDHCC. Any conflict of interest I might have as editor of this journal is that I am affiliated with the NYU Langone Medical Center. I extend an invitation to our readers to submit information about other programs around the country that provide comprehensive medical care accounting for psychiatric, social, and cultural needs of patients and their families. We will consider it as the focus of a future issue of Primary Psychiatry. PP



1.    Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders. Available at: www.med.nyu.edu/hassenfeld. Accessed June 12, 2008.



Ms. Nesbitt is music therapist and Ms. Tabatt-Haussmann is art therapist in the Pediatrics Department at New York University Langone Medical Center in New York City.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Kim Tabatt-Haussmann, MA, ATR-BC, Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, 160 E 32nd St, Second Floor, New York, NY 10016; Tel: 212-263-9923; Fax: 212-263-8410; E-mail: kim.tabatt@nyumc.org.



Focus Points

• The use of the creative arts therapies in pain management is a successful non-pharmacologic intervention.
• The presence of music and art therapy provide a context of normalization for a child in a medical environment.


The positive effects of art and music therapies for distraction during medical visits and procedures have been well studied. These interventions can reduce anxiety, promote relaxation, and minimize the perception of pain. This article describes combined art and music therapy interventions in the pediatric oncology/hematology environment and discusses various goals addressed during out-patient visits. Patient experiences are described as they relate to engagement in procedural accompaniments, creative arts therapy groups, individual therapy sessions, and group music therapy sessions. Interventions discussed include art making, active music listening, progressive muscle relaxation, music technology, active participation in music making, songwriting, and lyric analysis. The patients’ social, emotional, cognitive, and physical outcomes are discussed as they relate to treatment. In addition, the significance of the interventions for creative arts therapy practiced and researched is explored.



For over 50 years, creative arts therapists have been used in hospital environments to facilitate relaxation, decrease anxiety, and provide distraction. During this time, extensive research documented in medical journals has proven that non-pharmacologic interventions such as art and music therapy have a positive impact on the patient’s quality of life.1-5

The following description offers insight into the interventions provided by the art and music therapists at an outpatient pediatric hematology/oncology clinic at New York University Langone Medical Center. Both therapists worked individually with patients and families and exercised their specific skills to achieve various goals, including facilitating relaxation, providing social and peer interaction, decreasing anxiety, and providing an environment to normalize the patient within the medical environment. In the past year both disciplines collaborated so that patients and their families could have more opportunities to actively participate in the creative arts. The outcome was extremely positive.


The Creative Arts Defined

Music therapy is the art of using music to address a non-musical goal. In pediatric medical settings, the music therapist particularly focuses on decreasing a patient’s anxiety and normalizing the hospital or clinical environment through music activities.1-5 A variety of interventions can be used to bring about relaxation, promote normalization, and provide distraction, including progressive muscle relaxation with music, music and imagery, hypnosis, procedural accompaniment, songwriting, lyric analysis, and music and movement.1-5

In a medical environment, the music therapist works with patients, families, and medical staff in the treatment room. During various procedures, the therapist engages the patient in live music and introduces relaxation skills, including self-hypnosis, progressive muscle relaxation, and music-assisted imagery, to distract the patient from pain and decrease anxiety. Music therapy establishes a “therapeutic environment that enhances the effects of medication and involves patients in activities that direct attention away from the stresses of illness.”3 Once patients focus less on the stress and anxiety of an illness, their perception of pain often abates. West4 relates that relaxation, a goal in music-therapy interventions, decreases muscle tension and anxiety and results in a “positive influence on pain perception, nausea, and other symptoms.”

Art therapy, with the creative process of art making, improves and enhances the physical, mental, and emotional well being of individuals of all ages. It is based on the belief that clinical intervention with the act of art making can heal patients and enhance their quality of life while helping to reduce stress, increase self awareness, and cope with difficult experiences.6-11

Medical art therapy is a term applied to “the use of art expression and imagery with individuals who are physically ill, experiencing trauma to the body, or who are undergoing aggressive medical treatment such as surgery or chemotherapy.”7 A study of the innovative use of art therapy in relieving symptoms in cancer provides beginning evidence for the efficacy of art therapy in reducing a broad spectrum of symptoms in cancer patients.8

“When art therapy is partnered with medical treatment, children can meet the challenges of serious illness. For instance, when children create art in the medical setting, they have a sense of the familiar that produces pleasurable and positive associations. The child artist gains control by mastering art materials and developing personal imagery in a situation that is often out of his/her control.”9

A study of art therapy as a support for children during painful procedures was shown to be a useful intervention that can prevent permanent trauma and support children and parents during intrusive interventions.10

In medical settings, when children are not well enough or are unable to visit the playroom for an art therapy group, individual art therapy sessions can be provided in the treatment room so as to normalize their clinic environment and provide opportunities for socialization and expression.

“One of the contributions of art therapy to cancer treatment is the possibility of helping young people emerge from their illness as emotionally whole and healthy as possible. Encouraging growth and development through art activities can help the ill child preserve many areas of normal functioning.”12


A Collaborative Approach: Art and Music Group at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders

Art therapy and music therapy used collaboratively in a group provides the children and families with an outlet for stress management. In such an environment, they can sustain social and peer interactions as well as normalization. In addition, they have an opportunity to develop effective coping skills. Furthermore, art and music “therapists can address the functional skills of individual patients and encourage improved social skills, while providing the emotional outlet that is necessary for patients and families involved” in treatment for cancer and blood disorders.5 The art and music group takes place 1–2 times a week during clinic hours. Patients are invited to the Wellness Room, which is a large, open, non-threatening space with ceiling tiles designed as night-time stars. A large sheet of blank mural paper lies in the center of the room, and plush pillows and blankets are placed around the art area for the patients’ comfort. Children, parents, and siblings are assisted into the room, and markers, crayons, colored pencils, foam cutouts, and a variety of other art mediums are available. The music therapist sitting on a bench near the art area begins the session by introducing a theme, such as a trip to the zoo, life under the sea, space exploration, future dreams, or the patient’s view of him- or herself. The music therapist chooses appropriate music for the theme, and the art therapist asks the patients to close their eyes or focus on the song lyrics. After the music therapist sings and plays the first verse of the song, the art therapist invites the children to draw, color, or paint what or how the music made them feel. As the group progresses, different songs related to the theme are introduced. This technique facilitates diverse imagery evident by the distinctive pictures that appear on the mural paper. At the conclusion of the group, patients are asked to draw a final image reflecting the creative arts group theme. The result is a beautiful, unique mural designed by the participants that reflects their self-concept and emotions.


Benefits of Combining Art and Music Therapy

Combining art and music therapy at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC) of New York University Langone Medical Center not only increases the participants’ creativity but also distracts them from the clinic environment. The interventions offered within the group “focus the attention away from the physical sensation of pain to other aspects of the person.”13 Pediatric-oncology patients are confronted with numerous challenging situations, as most of them have to undergo chemotherapy, radiation, and surgery. Because of their treatment, they are unable to experience a carefree childhood. Since patients often experience the side effects of treatment, including pain and nausea, non-pharmacologic treatments are extremely important in distracting them from the psychological aspects of pain. Music and art therapies actively involve patients in the creative process and, as a result, are able to draw attention “toward the art and music.”9 Therefore, “when an investment in the art or music occurs, an exchange of energy results, and energy is refocused [away] from the pain.”13 When music and art work together to enhance the creative process, the outcome is positive because it reveals decreased anxiety, distraction from pain, and increased relaxation response.

The music and art therapy group also provides children and families with an opportunity to develop a positive social support group. Not only do pediatric patients miss out on classroom activities with their teachers and peers when they are at a clinic, but they miss out on being with their friends and participating in community activities as well. However, with the combination of music and art in a social setting, children are able to socialize with peers in similar circumstances and not feel as isolated. In the creative arts group, patients have the opportunity to feel normal, make friends, work on art together, play and sing, learn, and, most importantly, have fun in a safe creative environment.


The Music and Art Group Defined

Patients visit the outpatient clinic with parents/guardians, siblings, grandparents, other relatives and friends. Because cancer affects the child’s family and network of support, the therapists encourage and invite caregivers to actively participate in the creative arts group. Focusing on family-centered care, the group aims to reduce anxiety and educate participants on effective coping skills and relaxation tools to increase understanding and support. For each caregiver present, the group work reinforces the idea that the child’s creativity, imagination, development, and spirit are maintained and validated throughout their treatment.

The Music and Art Group is a 45-minute session that takes place in a controlled and comfortable space with minimal design and distraction. The Wellness Room is separate from the playroom and waiting room, which helps participants focus on the music and art. Mural paper is placed in the middle of the floor as well as markers, crayons, foam shapes, and colored pencils. Pillows surround the paper, posing as comfortable seats for the participants.

The therapists decide on a theme for the group (eg, animals, beach activities, rainbows, water and outer space) that has vivid imagery related to it. After the music therapist collects appropriate song material, both therapists gather the patients to begin the group. The art therapist provides various materials and co-facilitates guiding participants in imagery before the art creating begins.

The group is encouraged to sit comfortably and participate in active listening, a music therapy intervention. As the music therapist performs the song, participants are asked to listen to the music, close their eyes, and imagine the pictures that come to mind from the song lyrics. Songs performed in the past to elicit vivid imagery include “Going to the Zoo,” “Under the Sea,” “Rocketship Run,” and “Puff the Magic Dragon” (Figures 1–4).


While the music therapist continues to perform a variety of theme-related songs, the patients and families, who often sing along, are encouraged by the art therapist to begin drawing images on the mural paper. While they are listening and singing, the art therapist helps the participants think about the song and images that come to mind. Working on one piece of mural paper, which is a metaphor for the group working together, encourages therapeutic play through image making. One initial image inspires another and gradually transforms the mural into storytelling through music and art.

While the group is creating images and listening to the music, individuals often talk about their drawings, and others sing and dance to the music. As they observe the dynamics of the group, the leaders reinforce the idea that there is no right or wrong method.

As the session ends, the therapists review the journey and discuss the images created on the mural paper, naming the particular songs that guided the patients’ imagination. Participants are encouraged to first discuss the images and music then choose a title for the group mural. All participants sign their names on the artwork, an act which increases their self-esteem, produces self-actualization, and provides positive reinforcement for their creative abilities. The group mural is then displayed in the playroom for the SDHCC’s staff, patients, and families. The participants take pride in their finished product, and as a result, more patients are encouraged to participate in the next creative arts group.



Art and music therapy used together is extremely effective, especially with pediatric oncology/hematology patients, because it helps them address the physical issues of pain as well as the emotional issues in a non-pharmacologic and non-threatening way. The dynamics of sound and its impact on physical symptoms should be understood. For example, when sound travels through the “reticular activating system of the brain stem [and] coordinates sensory input, it alerts the cortex to incoming information.”1 Therefore, when the brain is activated, the sound “competes for cognitive awareness” and causes pain and nausea to be ignored.1

Music therapy and its effect on anxiety and relaxation have been well documented in research and case studies over the years.2,5,13,14 Hanser2 reports decreased scores on the A-State Anxiety Inventory in the presence of induced anxiety when music is playing, whereas Trauger-Querry relates that music has a way to “engage, activate and alter affective, cognitive and sensory processes through distraction, alteration of mood, improved sense of control, the use of prior skills and relaxation.”2,13 Exercising these skills and establishing a normal environment where pediatric patients can play and have fun without thinking about their illness is of paramount importance.
Imagery, facilitated by the art and music therapist, is another layer that can be added to musical stimuli in diverting pain perception. A study in which progressive muscle relaxation and guided imagery was used to delay or prevent “chemotherapy-induced nausea and vomiting” with HIV patients was conducted, and the findings demonstrated that 24 hours after chemotherapy, the experimental group, having used guided imagery techniques, had decreased levels of nausea for up to 60 hours after treatment.15 As patients focus positively and reach new levels of awareness through music and art, their tension and anxiety decrease. PP



1.    Skaggs R. The Bonny Method of Guided Imagery and music in the treatment of terminal illness: a private practice setting. Music Therapy Perspectives. 1997;15(1):39-44.
2.    Hanser SB. Music therapy and stress reduction research. J Music Ther. 1985;22:193-206.
3.    Blom RC, Wylie ME. Guided imagery and music with hospice patients. Music Therapy Perspectives. 1986;3:25-28.
4.    West TM. Psychological issues in hospice music therapy. Music Therapy Perspectives. 1994;12(2):117-124.
5.    Barker VL, Brunk B. The role of a creative arts group in the treatment of clients with traumatic brain injury. Music Therapy Perspectives. 1991;9:26-31.
6.    Malchiodi C. Medical art therapy with children. London, UK: Jessica Kingsley Publishers; 1999.
7.    Malchiodi C. Introduction to special issue: art and medicine. Art Ther J Am Art Ther Assoc. 1993;10(2):66-69.
8.    Nainis N, Paice J, Ratner J, Wirth J, Lai J, Shott S.  Relieving symptoms in cancer: innovative use of art therapy. J Pain Symptoms Manage. 2006;31:162-169.
9.    Council T. Art Therapy with pediatric cancer patients: helping normal children cope with abnormal circumstances. Art Ther J Am Art Ther Assoc. 1993;10(2):78-87.
10.    Favara-Scacco C, Smirne G, Schilirò G, Di Cataldo A. Art therapy as support for children with leukemia during painful procedures. Med Pediatr Oncol. 2001;36(4):474-480.
11.    Walsh SM, Martin SC, Schmidt LA. Testing the efficacy of a creative arts intervention with family caregivers of patients with cancer. J Nurs Scolarsh. 2004;36(3):214-219.
12.    Council T. Art Therapy with pediatric cancer patients. In: Malchiodi C, ed. Medical Art Therapy with Children. 1st ed. New York, NY: Jessica Kingsley Publishers; 1999:91.
13.    Trauger-Querry B, Haghighi KR. Balancing the focus: art and music therapy for pain control and symptom management in hospice care. Hospice J. 1999;14(1):25-38.
14.    Logan T, Roberts A. The effects of different types of relaxation music on tension level. J Music Ther. 1984;21:177-183.
15.    Capeli B, Anastasi JK. A symptom review: nausea and vomiting in HIV. J Assoc Nurses AIDS Care. 1998;9(6):47-56.


Dr. Levenson is professor in the Departments of Psychiatry, Medicine, and Surgery, chair of the Division of Consultation-Liaison Psychiatry, and vice chair for clinical affairs in the Department of Psychiatry at Virginia Commonwealth University School of Medicine in Richmond.

Disclosure: Dr. Levenson reports no affiliation with or financial interest in any organization that may pose a conflict of interest.


This column begins a series reviewing the interface between dermatology and psychiatry. Dermatologists and primary care physicians frequently encounter important psychiatric issues affecting diagnosis and management of patients with dermatologic complaints. Psychiatrists contend with frequent pruritus and rashes in their patients. A study of psychiatric inpatients excluding those with known skin diseases found that 33% of patients reported itching.1 Psychological factors affect numerous dermatologic conditions including atopic dermatitis, psoriasis, alopecia areata, urticaria and angioedema, and acne vulgaris. Some dermatologic conditions are best considered as idiopathic functional disorders such as idiopathic pruritus, which can be generalized or focal (eg, pruritus ani, vulvae, scroti). Some primary psychiatric disorders present with primarily physical symptoms to dermatologists, including body dysmorphic disorder (BDD) and delusional disorder, somatic type (eg, delusions of parasitosis, delusions of a foul body odor). Indeed, most patients with delusions of parasitosis or BDD avoid visiting psychiatrists or other mental health professionals and resist referral. In addition, dermatologists see patients with compulsive behaviors that may be part of obsessive-compulsive disorder or stand alone (eg, trichotillomania, psychogenic excoriation, onychophagia). Factitious skin disorders include factitious dermatitis (ie, dermatitis artefacta) and psychogenic purpura. Another important aspect of the interface between psychiatry and dermatology is the range of dermatologic adverse reactions to psychotropic drugs. More detailed coverage of these topics can be found elsewhere.2,3 This part of the series focuses on atopic dermatitis and psoriasis.


Atopic Dermatitis

Atopic dermatitis (ie, atopic eczema) is a chronic skin disorder characterized by pruritus and inflammation (ie, eczema), starting as an erythematous, maculopapular rash. Scratching is hard to resist and leads to excoriation and secondary infection, resulting in lichenification. Atopic dermatitis is the most common inflammatory skin disease of childhood and remains fairly common in adults. It typically begins in children or adolescents with a personal or family history of atopic dermatitis, allergic rhinitis, or asthma. In most patients, atopic dermatitis is a recurrent, relapsing disorder, with a vicious cycle of itching and scratching that leads to chronicity.


Atopic Dermatitis and Stress

The onset or exacerbation of atopic dermatitis often follows stressful life events.4,5 Divorce or separation of parents and severe disease of a family member have been identified as particularly increasing risk.4 Adults with atopic dermatitis are more anxious and depressed compared with clinical and healthy control groups.6,7 Children with atopic dermatitis have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems.


Psychosocial Morbidity in Atopic Dermatitis

Atopic individuals with emotional problems may develop a vicious cycle between anxiety/depression and dermatologic symptoms. In one direction of causality, anxiety and depression are frequent consequences of the skin disorder. The misery of living with atopic dermatitis may have a profoundly negative effect on health-related quality of life (HRQOL) of children and their families. Intractable itching causes significant insomnia, and sleep deprivation leads to fatigue, mood lability, and impaired functioning. Teasing and bullying by children and embarrassment in adults and children can cause social isolation and school avoidance. The social stigma of a visible skin disease, frequent visits to doctors, and the need to constantly apply messy topical remedies all add to the burden of disease. Lifestyle restrictions in more severe cases can be significant, including limitations on clothing, staying with friends, owning pets, swimming, or playing sports. The impairment of quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal to that of asthma or diabetes.8

In the other direction of causality, anxiety and depression aggravate atopic dermatitis. This may occur via several possible mechanisms, including modulation of pruritus perception,9 perturbation of epidermal permeability barrier homeostasis,10 or acceleration of immune responses.6


Psychiatric and Psychological Treatments for Atopic Dermatitis

A wide variety of treatments for atopic dermatitis have been advocated to interrupt the vicious cycle of itching and scratching. Mental health interventions include psychological, behavioral, and psychoeducational therapies and psychotropic medications. There have been several randomized controlled trials of psychological and educational interventions (eg, relaxation training, habit reversal training, cognitive-behavioral techniques, stress management training) as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy, but the evidence base remains limited regarding their efficacy.11 Oral and topical doxepin have been used because its potent antihistaminic effects can reduce itching, and oral doxepin’s sedation can promote sleep. A systematic review of controlled trials12 of 47 different interventions concluded that there was reasonable evidence to support the use of oral cyclosporine, topical corticosteroids, psychological approaches, and ultraviolet light therapy. However, there was insufficient evidence to make recommendations regarding oral or topical antihistamines (eg, doxepin), maternal allergen avoidance for prevention, dietary restriction in established atopic dermatitis, hypnotherapy, and a variety of other orthodox and alternative medical interventions.



Psoriasis is a chronic, relapsing disease with characteristic scaly lesions varying from pinpoint plaques to extensive skin involvement, nail dystrophy, and often arthritis. Psoriasis is an equally common condition among men and women, affecting 1.5% to 2% of the population in industrialized countries, with onset usually in the third decade of life. Most patients with psoriasis experience unpredictable exacerbations throughout life. The pathogenesis of psoriasis appears to involve genetic and environmental factors, influencing the body’s systems of skin repair, inflammatory defense mechanisms, and immunity.2,3


Psoriasis and Lithium

A particular concern for psychiatrists is lithium-induced psoriasis, which typically occurs within the first few years of treatment. Male patients taking lithium appear to be more susceptible to developing cutaneous reactions to lithium than females. Even a very small amount of psoriasis can be distressing to patients and can undermine medication compliance. Lithium-induced psoriasis is sometimes resistant to psoriatic treatments but resolves after discontinuation of lithium.13 There have also been case reports of psoriasis precipitated or aggravated by olanzapine.14,15


Psychosocial Morbidity in Psoriasis

Psoriasis is associated with a variety of psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation. Psoriasis is associated with substantial impairment of HRQOL, negatively impacting psychological, vocational, social, and physical functioning.16 Not surprisingly, appearance-related concerns dominate the experiences of young people with psoriasis.17 A theme running through the psoriasis literature is conveyed in the conclusion from a systematic review of psychosocial burden of psoriasis: “Social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity.”18

A recent cross-sectional study19 of 265 adults with prevalent psoriasis found that 32% of subjects screened positive for depression, with a graded relationship between depressive symptoms and impairment of HRQOL. Only 16.5% of those with high depression scores were receiving treatment for the condition. Depression was highly associated with both illness-related stress and dissatisfaction with antipsoriatic treatment. It was not associated with objective measures of psoriasis severity.19 A survey of 2,391 Italian adults with psoriasis using the Center for Epidemiological Studies-Depression Scale questionnaire found 62% of patients presenting depressive symptomatology. There was no difference in gender; however, younger men were more likely to report depressive symptoms than older men as were all subjects with less education.20

The emotional effects and functional impact of the disease are not necessarily proportionate to the clinical severity of psoriasis.21 In general, psychological factors, including perceived health, perceptions of stigmatization, and depression, are stronger determinants of disability in patients with psoriasis than are disease severity, location, and duration.22 It is not surprising that perceived stress in patients with psoriasis as well as numerous chronic diseases predicts poorer quality of life.23

Studies of the relationship between psychological factors and psoriatic disease severity have been primarily focused on depression. Some investigators found the condition correlated with objective measures of psoriasis severity24 and others have not.19 In a large double-blind, placebo-controlled trial of etanercept,25 which is an effective treatment for the clinical symptoms of psoriasis, patients who received etanercept had significant improvement in both fatigue and depressive sympomatology. Improvement in fatigue was correlated with decreasing joint pain, but improvement in depressive symptomatology was less correlated with objective measures of skin clearance or joint pain.

In a recent prospective study of patients with psoriasis,26 the frequency of psychiatric disturbance decreased with improvement in the clinical severity and symptoms of psoriasis. Other predictors of psychiatric improvement included no psoriatic involvement on the face and sex (ie, women were less likely to improve psychologically). However, the authors concluded that “dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.”26

Psoriasis and Suicide

In addition to the effects of depression on possibly triggering psoriasis and certainly reducing disease-related quality of life, suicide is a concern. One study found that 10% of adults with psoriasis reported suicidal ideation during the previous 2 weeks.27 Gupta and Gupta28 reported suicidal ideation in 2.5% of psoriasis outpatients and 7.2% of inpatients. In an earlier study of a different sample, Gupta and colleagues29 found that 9.7% of patients with psoriasis reported a wish to be dead, and 5.5% reported active suicidal ideation at the time of study. Death wishes and suicidal ideation were associated with higher depression scores and higher patient self-ratings of psoriasis severity.


Psoriasis and Stress

Stress has long been reported to trigger psoriasis.2,3 Uncontrolled studies have reported very high rates of stressful life events preceding the onset of the illness (eg, 68% of adult patients in one study,24 and 50% of children and 43% of adults in another).30 However, perception and recall biases influence such rates. A cross-sectional study23 of 141 adults found that approximately 66% strongly believed that stress was a causal factor for their psoriasis. This belief was significantly associated with higher levels of anxiety, depressive symptomatology, and perceived stress, but there was no association between perceived stress objective measures of psoriasis severity. A large case-control study31 comparing 560 patients with psoriasis to 690 patients with a new diagnosis of skin disease other than psoriasis found a high index of stressful life events associated with patients having more than double the risk of psoriasis compared to low scorers. However, the same study found that current and ex-smokers had approximately double the risk of psoriasis. Not all studies have supported the widely held belief that stressful life events precipitate psoriasis. For example, an investigation32 of outpatients experiencing a recent onset or exacerbation of psoriasis found no difference when comparing them to outpatients with skin conditions in which psychosomatic factors are regarded as negligible. Ultimately, however, most patients who report episodes of psoriasis precipitated by stress describe disease-related stress, resulting from the cosmetic disfigurement and social stigma of psoriasis, rather than stressful major life events or nonspecific distress.2,3

In an experimental study, 40 patients with chronic plaque psoriasis and 40 age-matched normal controls were subjected to acute psychological stressors (ie, cognitive, emotional, social). Patients with psoriasis and, in particular, those who believed that their psoriasis was highly stress responsive, were found to exhibit altered hypothalamic-pituitary-adrenal response to acute social stress, specifically lower post-stressor cortisol levels. The implication is that such patients may perhaps be more vulnerable to flares of their psoriasis.33 The mechanism of stress-induced exacerbations of psoriasis has been speculated to involve the nervous, endocrine, and immune systems, but no definitive pathways have been established. A more direct connection may be the effects of anxiety or depressive symptoms in reducing the threshold for pruritus in psoriatic patients.34

The adverse psychological sequelae of psoriasis are often but not always reduced by effective treatment of the disease, as noted in the study of disease-modifying therapy with etanercept cited earlier.25 A study16 that focused on systematic topical treatment for psoriasis found general quality of life significantly improved following treatment. Body image and appearance, self-esteem, and negative feelings were particularly responsive to clinical change. Domains of spirituality, independence and physical health also improved.


Psychiatric and Psychological Treatments for Psoriasis

There have been case reports of dramatic improvement in psoriasis after anxiolytic drug treatment but no controlled studies. The use of psychological therapies for patients with psoriasis has been proposed based on observations that the severity of their disease may correlate with emotional stress. Meditation, hypnosis, relaxation training, cognitive-behavioral stress management, and symptom control imagery training have received support in controlled trials for their effectiveness in reducing psoriasis activity,2,3 but this evidence base is limited by the size and short duration of the studies. A small (n=51) randomized controlled trial35 of a psychological intervention that entailed seven sessions of individual psychotherapy, including stress management, guided imagery, and relaxation, found some evidence of modest benefit on psoriasis activity.

A small (n=40) nonrandomized, age- and sex-matched case-controlled psychological intervention trial36 investigating the effects of a cognitive-behavioral psoriasis symptom management program showed significant reductions in illness identity (ie, the frequency and severity of symptoms that patients associate with their condition), the strength of belief in severity of consequences of their illness, and patients’ attributions for emotional causes of their psoriasis. PP



1. Mazeh D, Melamed Y, Cholostoy A, Aharonovitzch V, Weizman A, Yosipovitch G. Itching in the psychiatric ward. Acta Derm Venereol. 2008;88(2):128-131.
2. Arnold L. Dermatology. In: Levenson JL, ed. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2005:629-646.
3. Arnold L. Dermatology. In: Levenson JL, ed. Essentials of Psychosomatic Medicine. 1st ed. Washington, DC: American Psychiatric Publishing; 2007:237-260.
4. Bockelbrink A, Heinrich J, Schäfer I, et al. Atopic eczema in children: another harmful sequel of divorce. Allergy. 2006;61(12):1397-1402.
5. Picardi A, Abeni D. Stressful life events and skin diseases: disentangling evidence from myth. Psychother Psychosom. 2001;70(3):118-136.
6. Hashizume H, Horibe T, Ohshima A, Ito T, Yagi H, Takigawa M. Anxiety accelerates T-helper 2-tilted immune responses in patients with atopic dermatitis. Br J Dermatol. 2005;152(6):1161-1164.
7. Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders. Am J Clin Dermatol. 2003;4(12):833-842.
8. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
9. Gupta MA, Gupta AK. Depression modulates pruritus perception. A study of pruritus in psoriasis, atopic dermatitis and chronic idiopathic urticaria. Ann N Y Acad Sci. 1999;885:394-395.
10. Garg A, Chren MM, Sands LP, et al. Psychological stress perturbs epidermal permeability barrier homeostasis: implications for the pathogenesis of stress-associated skin disorders. Arch Dermatol. 2001;137(1):53-59.
11. Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2007;(3):CD004054.
12. Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191.
13. Yeung CK, Chan HH. Cutaneous adverse effects of lithium: epidemiology and management. Am J Clin Dermatol. 2004;5(1):3-8.
14. Latini A, Carducci M. Psoriasis during therapy with olanzapine. Eur J Dermatol. 2003;13(4):404-405.
15. Ascari-Raccagni A, Baldari U, Rossi E, Alessandrini F. Exacerbation of chronic large plaque psoriasis associated with olanzapine therapy. J Eur Acad Dermatol Venereol. 2000;14(4):315-316.
16. Skevington SM, Bradshaw J, Hepplewhite A, Dawkes K, Lovell CR. How does psoriasis affect quality of life? Assessing an Ingram-regimen outpatient programme and validating the WHOQOL-100. Br J Dermatol. 2006;154(4):680-691.
17. Fox FE, Rumsey N, Morris M.”Ur skin is the thing that everyone sees and you cant change it!”: exploring the appearance-related concerns of young people with psoriasis. Dev Neurorehabil. 2007;10(2):133-141.
18. Kimball AB, Jacobson C, Weiss S, Vreeland MG, Wu Y. The psychosocial burden of psoriasis. Am J Clin Dermatol. 2005;6(6):383-392.
19. Schmitt JM, Ford DE. Role of depression in quality of life for patients with psoriasis. Dermatology. 2007;215(1):17-27.
20. Esposito M, Saraceno R, Giunta A, Maccarone M, Chimenti S. An Italian study on psoriasis and depression. Dermatology. 2006;212(2):123-127.
21. Russo PA, Ilchef R, Cooper AJ. Psychiatric morbidity in psoriasis: a review. Australas J Dermatol. 2004;45(3):155-159.
22. Richards HL, Fortune DG, Griffiths CE, Main CJ. The contribution of perceptions of stigmatisation to disability in patients with psoriasis. J Psychsom Res. 2001;50(1):11-15.
23. O’Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res. 2004;57(5):465-471.
24. Devrimci-Ozguven H, Kundakci TN, Kumbasar H, Boyvat A. The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients. J Eur Acad Dermatol Venereol. 2000;14(4):267-271.
25. Tyring S, Gottlieb A, Papp K, et al. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial. Lancet. 2006;367(9504):29-35.
26. Sampogna F, Tabolli S, Abeni D. The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study. Br J Dermatol. 2007;157(3):508-513.
27. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol. 2006;54(3):420-426.
28. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol. 1998;139(5):846-850.
29. Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation in psoriasis. Int J Dermatol. 1993;32(3):188-190.
30. Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17(3):174-178.
31. Naldi L, Chatenoud L, Linder D, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol. 2005;125(1):61-67.
32. Picardi A, Pasquini P, Cattaruzza MS, et al. Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study. J Psychosom Res. 2003;55(3):189-196.
33. Richards HL, Ray DW, Kirby B, et al. Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis. Br J Dermatol. 2005;153(6):1114-1120.
34. Gupta MA, Gupta AK, Schork NJ, Ellis CN. Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psychosom Med. 1994;56(1):36-40.
35. Zachariae R, Oster H, Bjerring P, Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. J Am Acad Dermatol. 1996;34(6):1008-1015.
36. Fortune DG, Richards HL, Griffiths CE, Main CJ. Targeting cognitive-behaviour therapy to patients’ implicit model of psoriasis: results from a patient preference controlled trial. Br J Clin Psychol. 2004;43(Pt 1):65-82.


Needs Assessment: Psychosocial interventions that address the needs of the whole person have been shown to provide unique benefits to both patients and their families. This is especially relevant and challenging when treating pediatric patients having particular needs. Horticultural therapy is being increasingly offered as a psychosocial intervention designed to meet a variety of needs for many patient groups.

Learning Objectives:
• Understand the history and uses of horticultural therapy.
• Understand horticultural therapy as a psychosocial intervention.
• Understand the importance of developmentally appropriate interventions for pediatric hematology/oncology patients.

Target Audience: Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 4, 2008.

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by July 1, 2010 to be eligible for credit. Release date: July 1, 2008. Termination date: July 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Primary Psychiatry. 2008;15(7):73-77


Ms. Fried is horticultural therapist and Mr. Wichrowski is senior horticultural therapist in the OT/PT Department at the Glass Garden, Rusk Institute at New York University Langone Medical Center in New York City.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Matthew J. Wichrowski, MSW, HTR, Glass Garden, Rusk Institute, NYUMC, 400 E 34th St, New York, NY 10016; Tel: 212-263-6058; Fax: 212-263-2091; E-mail: matthew.wichrowski@nyumc.org.





Quality psychosocial care for patients undergoing treatment for hematology/oncology disorders and their families serves to reduce the inevitable disruptions in life experienced during treatment. Horticultural therapy, a process through which plants and gardening activities are used as vehicles in professionally conducted programs of therapy, is a program option that can address the psychosocial needs of patients in numerous medical situations. The horticultural therapy program at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders of New York University Langone Medical Center is designed to stimulate sensory, cognitive, and communication skills as well as increase knowledge and awareness of nature while providing a stress-reducing diversion during treatment. This program provides a range of benefits that complement other treatment options and serves to help minimize potential challenges in the quality of life for patients and their families.



Current trends in care for patients undergoing treatment for hematology/oncology issues increasingly include programs that address psychosocial needs as part of the treatment regimen.1-3 Various psychosocial interventions have shown potential to help normalize the treatment process,1 decrease the stigma of treatment,4 and help reduce the negative impact of the condition.3 These treatment issues are especially important when the patient is a child or adolescent. Their developmental stages and needs create extra challenges in ensuring positive outcomes.5 Through well-defined psychosocial practices, children and families are better prepared to cope with cancer and become well-adjusted survivors.3 Horticultural therapy is increasingly offered as a program component providing an array of psychosocial benefits for many groups of patients.

Biophilia is described as our predisposition to react positively to natural settings that suggest safety and shelter; offer hope for sources of food, medicine, and tools; and provide aesthetic enjoyment.6 Nature has been utilized as a therapeutic aid for thousands of years. Egyptian court physicians prescribed taking walks in the palace gardens for mentally disturbed members of royalty. Benjamin Rush, MD, founder of Friends Hospital, observed that field labor in a farm setting had a curative effect on patients. After World War I, horticultural activities were used with veterans during their occupational therapy sessions at Menninger’s Clinic.7

Today, horticultural therapy is the process through which plants and gardening are used as vehicles in professionally conducted programs of therapy.7 Horticultural therapy is used with individuals of all ages in a wide variety of applications including work in mental health,8 with people who have developmental disabilities,9 in educational settings,9,10 and in diverse healthcare settings.11-14

Although there is only a modest number of studies describing the clinical effects of horticultural therapy, an increasing body of literature supports the benefits of both passive and active interaction with nature. Ulrich15 reported decreased use of narcotic analgesics when compared to acetaminophen and a slightly shortened length of stay when cholecystectomy patients had a view of a landscaped area compared to patients who had a view of an adjacent building. In other studies, changes in physiologic indicators corresponding with stress reduction, including lowered heart rate,15,16 have been reported. Likewise, cognitive restoration in newly diagnosed breast cancer patients17 and enhanced mood in cardiac rehabilitation patients16 have been documented.

In practice, horticultural therapy provides a wide range of benefits in physical, emotional cognitive and social domains. Gardening is a popular avocational activity, exercising fine and gross motor skills, range of motion, strength maintenance, and endurance.18 Emotional benefits include enhanced self-esteem and mood.16,19 Learning about plants provides cognitive stimulation, as it exercises sequencing memory, and work with plants helps reduce stress.20 In addition, a wide range of social benefits can be achieved by a skilled therapist such as instillation of hope, universality, and imparting information.21


Program Description

The Glass Garden at Rusk Institute is the home base for the horticulture program at the Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders (SDHCC). Since its inception in 1959, the Glass Garden has provided a tranquil respite for patients, families, visitors, and staff of the SDHCC.
Initially, the conservatory was maintained as an amenity for the patients to visit and enjoy. However, the patients wanted more than just a visit; they wanted to work with the plants while they were there. This desire, coupled with the birth of the field of clinical horticultural therapy in the early 1970s, changed the role of the Glass Garden and the Glass Garden staff. Once merely a place for passive enjoyment of nature, the garden, which is now staffed with professional horticultural therapists, became a hub for helping, healing, and empowerment.

Today, the Glass Garden is far more than the original conservatory. When the current director, Nancy Chambers, came on board in 1986 she embraced a mission to develop the garden and its programs to reach far beyond the four glass walls of the original building. Her vision has seen the addition of a fully accessible perennial garden and an award-winning, state of the art, children’s PlayGarden that is regarded as a model to replicate in healthcare garden design.

Programming at the Glass Garden has also taken on new dimensions. In addition to four 1-hour intergenerational groups per day for inpatients at Rusk Institute, the staff runs horticulture programs in the Rusk Pre-school, Tisch Hospital Pediatric Child-Life Program, Psychiatric Unit, Cardiac Rehabilitation Unit, and Epilepsy Unit. The garden hosts programs for schools, senior centers, aphasia community groups, Alzheimer’s and dementia support groups, psychiatric day programs, adult day care, and nursing homes.

One of the most requested services at the Glass Garden is a staff therapist to conduct regularly scheduled horticulture groups at an off-site location. One such program at a senior center has been running for >6 years.

This is the kind of program that is currently running at the SDHCC. In 2006, the Glass Garden’s horticultural therapy team began a pilot program at the center’s New York City location. The team at the SDHCC was committed to adding this component to their innovative treatment milieu so they worked around the limited space and other logistical issues to fit the nature-based activity group into the weekly program. The new location at the upgraded space has really helped develop a vigorous program.



Each week, the horticultural therapist brings a plant or group of similarly themed plants to the center. The participants will plant them using the pots, sterile potting mix, plant labels, saucers, and anything else needed for the project. The Child-Life staff recruits medically cleared patients, their parents, siblings, care givers, and other staff members interested in participating. Class begins with participants’ introductions followed by an overview of the plant or project presented. Country of origin, history, culture, folklore as well as culinary and medicinal uses are topics available for discussion. The group’s theme can center on holidays, seasons, weather, geography, or other science topics. Each class may be different depending on the experiences, interests, and needs of its members. The leader demonstrates the project. Then, each group member completes his or her plant or project to take home.

Care is taken to provide numerous opportunities for decision making. For example, participants may choose which plant they want, how many cuttings they want to take, and what size pot is needed. The participants label the finished project with their name, name of the plant, and date. At the end of the class, participants talk about where they are going to keep their plant when they return home and review how to take care of it. The leader often asks how participants liked the class, but by this time the members are often involved in casual conversation about home, hobbies, and other normal activities.


Program Goals

The first goal of the program is to provide respite for the children and their family members while they receive treatment at SDHCC. Many of the center’s patients are from countries other than the United States. Because most houseplants are from tropical or subtropical countries, the plant is often recognized as something from their home country. This often leads to sharing nostalgic stories about home, family, and friends. The child or parent may even assume the role of teacher, telling other members of the group how the plant is used in their homeland. A once overwhelmed caregiver has transformed into a teacher, sharing knowledge and information while experiencing a sense of empowerment that reaches far beyond the class.

The second goal of the program is to offer hands-on experiences with nature to stimulate sensory, cognitive, and communication skills. Numerous families at the center are there for outpatient treatment after an admission to an acute care hospital. Coming from a setting where gowns and gloves are the norm, they are often apprehensive toward touching anything in the “outside world.” With the center’s safe environment, families are reintroduced to these tactile and sensory experiences while being educated on safe ways to handle soil and plant material when they are at home (Figure 1). As the educational conversation and the planting continue, members tend to let down their guard. The colors, smells, and textures of nature begin to take over. The experience becomes such a total sensory immersion that is so different from the clinical environment that members report momentarily forgetting where they are and why they are together (Figure 2).




A third goal is to introduce horticulture projects that increase knowledge of nature, science, nutrition, and environmental concepts. Each program is designed to be well rounded and rich in content. One class on planting ginger began with a challenge to the group members to see if anyone could recognize the root on the table. Clues of ginger ale and gingersnaps helped those who had trouble. At this point group members may discuss ginger roots in India, how the plant is produced or used in recipes, or medicinal uses from days gone by. Someone usually remembers a parent or grandparent giving him or her ginger ale as a remedy for nausea. If they ask, patients are encouraged to check with their doctor to see if they can use ginger tea or ginger ale as a remedy for the side effects of treatment (Table).



Positive Themes Cultivated in Horticultural Therapy Groups

 One of the favorite groups for children and adults alike is the ketchup class. Tomatoes and other ingredients are put together to make tomato ketchup. The product tastes just like the condiment that they know and love. Many participants are surprised to see what is in ketchup and they can easily create fresh ketchup at home without any chemical additives. In addition, they discuss how they can adjust this recipe to make a more sophisticated version custom flavored to their taste preferences.

Another positive theme occurs when planting a seed, root, or seedling comes with an expectation of change and growth. This implies hope for the future. As the participants complete the planting project they talk about what to expect as the plant grows. Comments like, “when that has roots, we will be done with these treatments” or “this plant will be 6 inches tall by your birthday” convey hope and allow the patient to recognize hope in the voices of a caregiver, parent, or child. Hope can be a powerful psychological factor in cancer treatments influencing prognosis and quality of life (Figure 3).21


One of the benefits of the program was not initially intended. The scope of programs at the Glass Garden touches all areas of the hospital and that means very often the therapist sees patients or their families in acute care, rehabilitation, and outpatient care at the SDHCC. It is very comforting for the patients to see a familiar face when they enter another phase of their treatment. Comments like, “I guess you are one big family,” tell us that this is very settling for patients and their families to have familiarity from place to place on their journey.



While the goals of the horticultural therapy option mesh well with the overall goals of the SDHCC in meeting the needs of patients and their families, there is limited empirical support for this relatively new treatment modality. More research is needed to document the benefits of horticultural therapy. Researching psychosocial interventions presents an array of methodologic challenges, particularly when team treatment approaches are used. Evaluating the effects of horticultural therapy on mood, stress, and distraction from discomfort during treatment, as well as on quality of life and overall satisfaction with treatment, would be helpful in determining the range of benefits that horticultural therapy programming provides and in what settings it is most effective.

Overall, horticultural therapy provides a treatment option addressing numerous needs for patients and their families at the SDHCC. Offering a variety of psychosocial interventions as part of the treatment team respects individual preferences and offers choice and some sense of control while battling a serious illness. Optimal cancer care balances the need for scientific knowledge, statistical analysis, and rational thought with the need for wisdom, kindness, compassion, and love.2 Integrated treatment that provides a diversity of options aimed at maximizing treatment effectiveness and minimizing potential complications while enhancing quality of life helps fight disease and promotes well being for all dimensions of a person. A treatment philosophy that honors the complexities of the human condition is a key feature in developing optimal healing environments in cancer care. PP



1.    Kusch M, Labouvie H, Fleisback G, Bode U. Structuring psychosocial care in pediatric oncology. Patient Educ Couns. 2000;40(3):231-245.
2.    Geffen JR. Creating optimal healing environments for cancer patients and their families: insights, challenges, and lessons learned from a decade of experience. J Altern Complement Med. 2004;10(suppl 1):S93-S102.
3.    Zeitzer L. Cancer in adolescents and young adults: psychosocial aspects. Cancer Suppl. 1993;71(10):3863-3868.
4.    Ritchie MA. Sources of emotional support for adolescents with cancer. J Pediatr Oncol Nurs. 1993;18(3):105-110.
5.    Redd WH. Advances in psychosocial oncology in pediatrics. Cancer Suppl. 1993;74(4):1496-1502.
6.    Kellert SR, Wilson EO. The Biophilia Hypothesis. Washington, DC: Island Press; 1993.
7.    Davis S. Development of the profession of horticultural therapy. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:3-18.
8.    Shapiro BA, Kaplan MJ. Mental illness and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:157-197.
9.    Catlin P. Developmental disabilities and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:131-156.
10. Morris JL, Zidenberg-Cherr S. Garden-enhanced nutrition curriculum improves fourth-grade school children’s knowledge of nutrition and preferences for some vegetables. J Am Diet Assoc. 2002;102:91-93.
11.    Frazel M. Botanical gardening: design, techniques, and tools. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:355-375.
12.    Wichrowski M, Chambers NK, Ciccantelli L. Stroke, spinal cord, and physical disabilities and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:71-104.
13.    Strauss D, Gabaldo M. Traumatic brain injury and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:105-130.
14.    Haas K, Simpson SP, Stevenson, NC. Older persons and horticultural therapy practice. In: Simpson SP, Strauss MC, eds. Horticulture as Therapy. Binghamton, NY: Haworth Press; 1998:231-256.
15.    Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421.
16.    Wichrowski M, Whiteson J, Haas F, Mola A, Rey MJ. Effects of horticultural therapy on mood and heart rate in patients participating in an inpatient cardiopulmonary rehabilitation program. J Cardiopulm Rehabil. 2005;25(5):270-274.
17.    Cimprich B. Development of an intervention to restore attention to cancer patients. Cancer Nurs. 1993;16(2):83-92.
18.    Lantz B. Therapeutic gardening with physical rehabilitation patients. Journal of Therapeutic Horticulture. 2006;17:35-38.
19.    Szofram J, Meyer S. Horticultural therapy in a mental health day program. Journal of Therapeutic Horticulture. 2004;15:32-35.
20.    Taft S. Therapeutic horticulture for people living with cancer: the healing gardens program at cancer lifeline in Seattle. Journal of Therapeutic Horticulture. 2004;15:16-23.
21.    Yalom ID. The Theory and Practice of Group Psychotherapy. New York, NY: Basic Books; 1995.
22.    Spiegel B. Love Medicine and Miracles. New York, NY: Harper Row; 1988.


e-mail: ns@mblcommunications.com


Dr. Sussman is editor of Primary Psychiatry and professor of psychiatry at the New York University School of Medicine in New York City.

Dr. Sussman reports no affiliation with or financial interest in any organization that may pose a conflict of interest.



An understanding of the etiology of schizophrenia has eluded theoreticians and investigators for centuries. The question of whether it is possible to recover from the disorder has also proven to be frustrating to those seeking an understanding of the true course of the illness. Three of the feature articles in this issue of Primary Psychiatry provide overviews of some of the most important recent findings about these issues.

Mark G. A. Opler, PhD, and colleagues present some of the more significant findings on schizophrenia. They note how there are multiple pathways to schizophrenia that may be reflected in neurobiologic differences, the heterogeneous clinical presentation of the disease, and in differential responses to treatment. Several findings about factors that increase risk have been confirmed. These include genes, particularly the evidence for genetic associations and the function of suspected susceptibility genes; advanced paternal age and potential mechanisms by which it exerts its influence on pathology; and selected environmental exposures, such as chemicals and poor nutrition. This article also reviews likely gene-gene and gene-environment interactions.

Cannabis, or marijuana, is the most widely used illegal drug in the United States, with nearly 45% of teenagers in the US having smoked cannabis before graduation from high school. Smoking cannabis is also common among young adults. It is viewed by many as a relatively benign recreational drug, but compelling evidence has implicated cannabis as a possible cause of schizophrenia. Despite the social acceptance of cannabis use, in part because there is a pervasive belief that cannabis use is benign, cannabis use can lead to psychosis. Lauren L. Bodkin, PsyD, and colleagues describe what may make some teenagers vulnerable to psychosis in the context of cannabis use, considers motivations for their use, and makes recommendations for treatment approaches to be used by clinicians, as based on the existing literature. They describe a particularly vulnerable subset of youths who possess a genetic variation that manifests in particular behaviors and experiences, including schizotypy. Apart from the psychiatric dimension of chronic cannabis use, the authors note, it has been estimated that smoking five joints/day may be equivalent to smoking one pack of cigarettes/day in terms of exposure to cancer-causing chemicals. In addition to outlining the varied risks associated with cannabis use, the article contains useful guidelines for intervention when clinicians encounter patients at elevated risk.

Paul H. Lysaker, PhD, and Kelly D. Buck, APRN, BC, summarize the results of data from multiple sources and observe that many psychiatric and general practitioners remain unaware that most people with schizophrenia will achieve significant periods of recovery during their lives. The authors note that while these data are grounds for optimism, the idea of recovery has been received with resistance and as an evolving concept it has yet to be defined in an agreed upon matter. Progressive deterioration was long considered a hallmark of schizophrenia, but evidence suggests that this is more the exception than the rule. Examples of recovery as a process include the resolution of problems associated with the illness, the development of an optimistic outlook on life, and the development of a sense of worth and intrinsic value. The article clarifies the concept of recovery and its implications for practice, and offers a review of definitions, operational criteria, and studies of the incidence and correlates of recovery from schizophrenia. They conclude with a review of clinical practices that might be employed to promote recovery. Even though gains are often followed by losses and relapse, the authors argue that these may become opportunities for insight and personal growth.

Mark Zimmerman, MD, and colleagues note that to determine the impact of treatment in clinical practice it is necessary to evaluate outcome. At the moment, assessments of outcome are typically based on unstructured interactions that yield unquantified judgments of progress. Even among psychiatrists, use of standardized scales to monitor outcome is rare. The authors explain why available self-report questionnaires are a cost-effective option to monitor outcome. They state that standardized scales should be routinely used to measure outcome when treating depression and that this should be the standard of care. They conclude with a challenge to readers who are not convinced by their arguments and who do not adopt a measurement-based approach toward treating depression. PP


Dr. Zimmerman is director of Outpatient Psychiatry at Rhode Island Hospital and associate professor in the Department of Psychiatry at Brown Medical School in Providence, Rhode Island. Drs. McGlinchey and Chelminski are assistant clinical professors in the Department of Psychiatry and Human Behavior at Brown University.

Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Mark Zimmerman, MD, Associate Professor, Department of Psychiatry, Brown Medical School, Bayside Medical Building; 235 Plain Street; Providence, RI 20905; Tel: 401-277-0724; Fax: 401-277-0726; E-mail: mzimmerman@lifespan.org.



Focus Points

• In mental health clinical settings, assessments of outcome are typically based on unstructured interactions that yield unquantified judgments of progress.
• The results of two surveys found that psychiatrists typically do not use standardized scales of established reliability and validity to monitor outcome when treating patients with depression.
• Self-report questionnaires are cost-effective options to monitor outcome because they are inexpensive in terms of professional time needed for administration and they correlate highly with clinician ratings. 
• Brief self-report scales are reliable and valid measures of depression and are feasible to incorporate into routine clinical practice.




Psychiatry is the only medical discipline in which quantified measurements of outcome are not the standard of care. In mental health clinical settings, outcome evaluations are typically based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is partially determined by the change of a numerical value. Body temperature, blood pressure, cholesterol values, blood sugar levels, cardiac ejection fraction, and white blood cell counts are examples of quantifiable variables that are used to evaluate treatment progress. In treating psychiatric disorders, standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. Recently, the term “measurement-based care” has been coined in reference to the use of standardized scales to measure the outcome of psychiatric treatment. This article  reviews perceived obstacles in adopting a measurement-based care treatment approach and illustrates how the use of self-report depression scales is feasible, acceptable to patients, and may improve outcome.


Imagine a patient going to his or her primary care physician (PCP) with symptoms of an upper respiratory track infection and a feverish feeling. Imagine the PCP placing his or her palm on the patient’s forehead and telling the patient that he or she feels warm. Imagine the PCP recommending both a course of treatment and a return visit in a few days. A few days later, the PCP again feels the patient’s forehead and notes improvement because the patient feels cooler. It is likely that a PCP who evaluated body temperature in this manner would soon be out of business.

To determine the impact of treatment, it is necessary to evaluate outcome. In mental health clinical settings, this typically is based on unstructured interactions that yield unquantified judgments of progress. Often judgments of outcome are based on broad-based, global questions such as “How are you feeling?” or “How are you doing?” These inquiries are similar to everyday discourse when greeting a friend or acquaintance. Correspondingly, patients often reply with global, ofttimes misleading, responses such as “okay” or “fine.” There have been patients who, at the beginning of the visit, indicate that they are “fine,” and by the end of the visit, it is agreed that hospitalization is warranted.

When treating depression, competent clinicians do not limit their assessments of outcome to global questions. Instead, they follow up with specific questions about the defining features of the disorder they are treating, including the symptoms of depression and domains of psychosocial functioning. However, even these questions are not usually used to evaluate outcome in a quantified manner. This is at variance with other areas of medical care in which outcome is partially determined by the change of a numerical value. Body temperature, blood pressure, cholesterol and triglyceride values, blood sugar levels, pulmonary function tests, electrolytes, cardiac ejection fraction, and white blood cell counts are examples of quantifiable variables used to evaluate treatment progress. In the mental health field, standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice.

The authors believe that standardized scales should be routinely used to measure outcome when treating depression. In fact, the authors believe that this should be the standard of care. The goal of this article is to review recent research related to the use of depression rating scales in routine clinical practice. First, the authors discuss a potentially important reason for systematic measurements (ie, the detection of residual symptoms in patients who have improved but not remitted from treatment). Second, they summarize the results of two surveys of psychiatrists’ use of scales to measure outcome. Third, they review the desirable features of a depression outcome scale. Fourth, they summarize research conducted in their clinical-research program on the reliability and validity of a self-administered scale that was designed with clinical utility in mind. Fifth, they summarize research on patients’ perspectives of the burden associated with completing scales in clinical practice. Last, they summarize the results of a research program that has demonstrated the therapeutic benefits of measurement in patients receiving psychotherapy.


One Reason Why Measurement May Be Important in Treating Depression: Improved Detection of Residual Symptoms

Measurement provides the clinician with information regarding the degree and completeness of treatment success. Suboptimal outcome in the treatment of diabetes, hypertension, hypercholesterolemia, or an infection would prompt intervention. For example, improvement in blood pressure from 165/105 to 145/95 is a positive yet incomplete response that would warrant an adjustment in treatment. Likewise, reducing total cholesterol from 280 to 240 is movement in the right direction, but it is insufficient and requires a change in treatment. The same should be true in the treatment of depression.

Research has consistently demonstrated that residual symptoms of depression in patients who have responded to treatment are at increased risk for relapse. For example, Paykel and colleagues1 followed up 64 treatment responders for 15 months. Patients who scored >8 on the Hamilton Rating Scale for Depression (HAM-D)2 (ie, nonremitters) were three times more likely to relapse during the follow-up interval than patients scoring ≤8 (76% versus 25%). Numerous follow-up studies3-9 have similarly found that the presence of residual symptoms in patients who responded to treatment robustly predicted poorer outcome.

How well do clinicians detect such residual symptoms? There are no studies that address this question. However, as described below, one research group has demonstrated that measuring outcome and providing feedback to treating clinicians significantly improved outcome.


Surveys of Psychiatrists’ Use of Standardized Scales to Measure Outcome

Gilbody and colleagues10 surveyed 340 psychiatrists in the United Kingdom regarding their use of outcome measures. Only 11.2% of psychiatrists routinely used standardized measures to assess outcome when treating depression and anxiety disorders. Greater than 50% of clinicians indicated that they never used standardized measures to evaluate outcome. The authors did not ask the respondents why they were disinclined to use scales to measure outcome; however, they noted that several respondents included comments on the questionnaires indicating that they thought such scales were simplistic, not useful in clinical practice, of questionable reliability and validity, or overly burdensome and costly to implement routinely.

Zimmerman and McGlinchey11 conducted a similar survey of 314 psychiatrists in the United States. Prior to delivering a lecture on the treatment and management of depression at continuing education conferences in California, Massachusetts, New York, and Wisconsin, audience members were asked to complete a brief questionnaire. The first part of the questionnaire elicited subjects’ demographic characteristics (ie, age, sex) and professional background (ie, practice setting and years in practice). The second part of the questionnaire included six questions, two of which addressed the use of rating scales. The first question was, “How often do you use a rating scale to monitor the course of treatment for depression?” Response choices included, “never,” “rarely,” “sometimes,” “frequently,” and “almost all the time.” The second question was intended to determine the reasons clinicians do not regularly use scales to monitor outcome. Accordingly, only subjects who responded “never,” “rarely,” or “sometimes” to the first question were asked to respond to the second question. The second question was, “Please indicate why you do not routinely use rating scales to monitor the course of depression?” Response choices included “I do not believe it would be clinically helpful,” “I do not know what measure to use,” “It takes too much time,” “It is too disruptive of clinical practice,” “I was not trained to use them, and “other.” The response choices were based on conversations with psychiatrists about why they do not use scales in clinical practice.

Similar to the results of Gilbody and colleagues,10 Zimmerman and McGlinchey11 found that the vast majority of psychiatrists did not routinely use scales to monitor outcome when treating depression. Greater than 50% of psychiatrists indicated that they never (28.8%, n=88) or rarely (32.0%, n=98) used scales to monitor outcome, and <10% almost always (6.5%, n=20) used scales to monitor outcome of depression treatment.

The authors of this article compared the characteristics of psychiatrists who reported using scales frequently or almost always to the rest of the group. There were no differences between the two groups in gender, age, years of practice, or practice setting. Subjects who reported never, rarely, or only sometimes using scales to monitor outcome were asked the reasons for not routinely using scales in their clinical practice. More than 25% of the subjects indicated that they did not believe using scales would be clinically helpful, that they take too much time to use, and that they were not trained in their use (Table 1).


The results of these two surveys, one in the UK and one in the US, indicate that psychiatrists typically do not use standardized scales when treating patients with depression. One issue identified as an obstacle in their use is the perceived burden of scale completion. In the future, if the delivery of mental health treatment increasingly requires the measurement of outcome, then the user friendliness of measurement tools, as well as their reliability and validity, will be critical to their widespread adoption. Clinicians are already overburdened with paperwork, and adding to this load mandatory repeated detailed evaluations with such instruments as the HAM-D is unlikely to meet with success. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration and correlate highly with clinician ratings. To be sure, there are also limitations with self-report questionnaires such as response set biases, and their use may be limited by the readability of the scale and literacy of the respondent. However, self-report scales are free of clinician bias and from clinician overestimation of patient improvement (which might occur when there are incentives to document treatment success).


Desirable Features of a Self-report Depression Outcome Scale

There is no shortage of measures to be used to monitor outcome. Two perspectives are of primary importance in deciding which measure to choose—that of the patient and the clinician. Patients should find the measure user-friendly and the directions easy to follow. The questions should be understandable and relevant to the patient’s problem. The scale should be brief, taking no more than 2–3 minutes to complete, so that upon routine administration at follow-up visits patients are not inconvenienced by the need to come for their appointment 10–15 minutes early in order to complete the measure. Brief scales can be feasibly completed at each follow-up visit in the same way that blood pressure and weight are routinely assessed in primary care settings for patients being treated for hypertension and obesity.

The instrument should provide clinicians with clinically useful information and improve the efficiency of conducting their clinical evaluation; thus, the measure should have practical value to the practicing clinician. Clinicians need to be able to trust the information provided by any instrument they use. Consequently, outcome measures for depression should have a sound basis in psychometrics, demonstrating good reliability, validity, and sensitivity to change. Clinicians and clinics should also find the instrument user-friendly; it should be easy to administer and score with minimal training.

During the past decade, the authors of this article have established and have been conducting the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. One of the goals of the MIDAS project has been to develop instruments for use in routine clinical practice. The authors have developed a broad-based self-report scale for psychiatric screening12-14; a clinician-rated outcome measure for depression15; single-item self-report indices of depression symptom severity, psychosocial impairment and quality of life (QOL)16; and two different self-report depression scales.17,18 One of these scales, the Diagnostic Inventory for Depression (DID),18 was designed to assess the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,19 symptom inclusion criteria for a major depressive episode, psychosocial impairment due to depression, and subjective QOL. However, with the respondent needing to read more than 100 statements, it may be too long to be feasible for use at every patient visit. On the DID, each symptom is assessed by groups of five statements arranged in order of increasing severity. Other scales that are constructed in a similar manner20-22 likewise are not conducive to routine clinical use because the relatively large number of statements that need to be read results in the measures taking more than 5 minutes to complete. More recently, the authors of this article developed a scale attending to the issue of clinical utility.17 The Clinically Useful Depression Outcome Scale (CUDOS) contains 18 items assessing all of the DSM-IV inclusion criteria for major depressive disorder (MDD) and dysthymic disorder as well as psychosocial impairment and QOL. The 16-symptom items are rated on a 5-point Likert scale in order to keep the scale brief. A copy of the scale is reproduced in the Figure.




Summary of Studies on the Reliability and Validity of the CUDOS

The CUDOS has undergone extensive testing of its psychometric properties and feasibility of use. Internal consistency reliability coefficients were computed separately for 1,475 patients who completed the scale at intake and 100 depressed patients who participated in an acceptance and feasibility study and completed it during a follow-up appointment.23 The CUDOS demonstrated excellent internal consistency in both samples (Cronbach’s alpha at intake=.90; Cronbach’s alpha at follow-up=.90). The test-retest reliability of the CUDOS was examined in 176 subjects at baseline and 33 subjects during follow-up. At both time points the test-retest reliability of the total scale was high (r=.92 and .95, respectively).

Discriminant and convergent validity was examined in 200 patients who completed a package of questionnaires at home an average of 1.2 days (SD=16.9) after the intake evaluation. The CUDOS was more highly correlated with the Beck Depression Inventory (BDI)20 (r=.81) than with measures of the other symptom domains such as posttraumatic stress disorder, alcohol use, and hypochondriasis (mean r=.35). Moreover, the CUDOS was almost as highly correlated with the HAM-D (r=.69) and the Clinical Global Index (CGI) of Depression Severity (r=.71),24 clinician ratings of the severity of depressive symptoms, as with the self-rated BDI. In a separate study of 267 patients evaluated during the course of outpatient treatment, the correlation between the CUDOS and HAM-D was .89.25

The CUDOS was able to discriminate between different levels of depression severity as rated on the CGI. The difference between each adjacent level of severity (eg, nondepressed versus minimally depressed and mild versus moderate) was significant. The data and clinical experience allowed the authors to derive empirically informed ranges of scores corresponding to a dimensional assessment of depression severity. The authors recommended that the nondepressed range corresponds to CUDOS scores of 0–10, minimal depression 11–20, mild depression 21–30, moderate depression 31–45, and severe depression ≥46.

Although the CUDOS was not primarily intended as a diagnostic measure, it performed well in this regard. Based on a Receiver Operating Curve analysis the area under the curve was .86. The sensitivity of the scale was 83.3%, specificity 72.1%, positive predictive value 72.6%, negative predictive value 82.9%, and chance-corrected agreement level k=.55.

The scale was sensitive to clinical change. Fifty-five depressed patients completed the CUDOS a second time 6 weeks after initiating antidepressants and were rated at baseline and 6 weeks on the Montgomery-Asberg Depression Rating Scale (MADRS). Not only was the change in CUDOS scores correlated with the change in MADRS values, but the CUDOS was able to distinguish between treatment remitters and responders. The patients were divided into three groups using the MADRS to determine remission and response status. Patients scoring ≤10 at week 6 were considered to be in remission (n=29); patients improving ≥50% on the MADRS but who scored >10 at week 6 were considered responders (n=7), and the remaining patients were considered nonresponders (n=19). Remitters scored significantly lower than responders, and responders scored significantly lower than nonresponders.

In the study of 267 depressed psychiatric outpatients in ongoing treatment, the authors examined the ability of the CUDOS to identify remission according to the HAM-D threshold of ≤7.25 At a cutoff of <20, the CUDOS had a sensitivity of 87.4%, specificity of 87.8%, overall agreement of 87.6%, and kappa of .75.

The results of these studies indicate that the CUDOS is a reliable and valid measure of depressive symptoms that is sensitive to clinical change and can be used to determine whether depressed patients have remitted from treatment. The next important question is the clinical utility of the measure.


Feasibility of Using the CUDOS in Clinical Practice

The feasibility and acceptability of incorporating the CUDOS into routine clinical practice was examined in two studies of depressed psychiatric outpatients who were in ongoing treatment.23 In the first study, the amount of time needed to complete the CUDOS during a follow-up appointment with a psychiatrist was recorded in a consecutive series of 50 depressed outpatients presenting at a follow-up visit. The patients also completed a questionnaire assessing how burdensome it was to complete the scale during the visit (0=very little burden; 3=a large burden), and their willingness to complete the scale at every visit to help monitor the progress of their treatment (0=not at all willing; 3=very willing to fill it out at every visit). All but two patients completed the scale in <3 minutes (mean=102.7 seconds; SD=42.7). Almost all patients considered questionnaire completion very little or a little burdensome (98.0%, n=49), and no patient perceived it as very burdensome. More than 90% of patients indicated a willingness to complete the CUDOS at every visit in the future if their clinician believed that it was helpful (94%, n=47).

In the second study of feasibility, a separate sample of 50 depressed outpatients completed both the CUDOS and the BDI during a follow-up visit. After completing the two questionnaires the patients completed a questionnaire asking which of the two measures took less time to complete, was easier to understand, was less burdensome to complete, and was more acceptable to complete at every follow-up appointment. Significantly more patients indicated that the CUDOS took less time to complete, and was less of a burden to complete (Table 2). Nearly three times as many patients indicated that they would prefer to complete the CUDOS than the BDI to monitor the outcome of treatment (40.0% vs. 14.0%, P<.05).



These studies suggest that patients did not find scale completion burdensome. However, the likelihood that clinicians will change their behavior and incorporate systematic measurement in their treatment of depressed patients will increase if there is also evidence of the therapeutic benefit of standardized outcome assessment.


Does Measurement Improve Outcome?

Lambert and colleagues26-28 have conducted a series of studies during the past 20 years on the impact of measurement and feedback on psychotherapy outcome. All patients completed a self-report outcome scale prior to every therapy appointment. After the first visit, a patient’s progress was compared to the expected course of symptomatic and functional improvement. The expected level of improvement was based on benchmarking studies of thousands of patients who received psychotherapy in diverse settings and who completed the same outcome measure. From these benchmarking studies, “recovery curves” were derived that graphically illustrated the expected rate and level of improvement. In the intervention studies examining the therapeutic benefit of measurement, patients were randomized to a feedback or no feedback condition. All patients completed the outcome scale before each therapy visit; a research assistant scored the scale and compared the results to the empirically derived recovery curves; and in the feedback condition, information was placed in the patient’s chart indicating the adequacy of improvement. Inadequate levels of improvement were accompanied by a message suggesting either that treatment should be intensified or perhaps changed altogether. In the no feedback condition the therapists did not receive information from the outcome assessment.

The results of the aforementioned studies26-28 have consistently demonstrated the therapeutic benefit of standardized assessment and feedback. Combining the results of the first two studies of >1,500 patients, the authors found that the improvement rate in patients failing to achieve expected improvement was significantly higher when clinicians received feedback regarding patients’ relatively poor progress than in patients in the no feedback condition (30.5% versus 17.5%). Moreover, they found that among patients who were not responding to treatment, those who were randomized to the feedback condition received significantly more therapy visits than the patients randomized to the no feedback condition.

These studies have found that measurement and feedback was associated with improved outcome, and can influence therapists’ behavior insofar as more therapy visits were conducted with clients who were not doing as well as expected. To be sure, there are some limitations to this research program. All of these studies have been conducted with mildly ill clients receiving psychotherapy at a university counseling center. In addition, the measurement system was complex and relied on research assistants to score the measure and alert clinicians to the results. Such an approach is cost prohibitive for implementation in real-world clinical practice. As Lambert and colleagues27 themselves noted in the conclusion of their first replication study, “if client-focused outcome research is to have any applicability it must remain simple and easy to implement in day-to-day clinical practice.” Nonetheless, the results provide some empirical evidence of the therapeutic benefit of monitoring outcome.


Are You Using Scales to Monitor Outcome When Treating Depressed Patients?

The community standard of care for treating depression does not include routine use of reliable and valid scales to monitor outcome. The authors of this article believe that this is an inadequate and indefensible state of current practice. Would a physician treat diabetes without measuring glucose levels? Would he or she treat hypertension without measuring blood pressure or a febrile illness without measuring body temperature? Of course not; the same should be true of the treatment of depression.

The authors believe that systematic outcome assessment will assume increasing importance during the next decade, if for no other reason that payor mandates will require it. The Centers for Medicare and Medicaid Services’ Physician Quality Reporting Initiative (PQRI),29 signed into law in 2006, is intended to improve quality of care by providing physicians financial incentives to document outcomes reflecting best practices. In 2007, the first year of the PQRI, 74 indicators were listed, one of which was related to the treatment of depression (percentage of patients ≥18 years of age diagnosed with new episode of MDD and documented as treated with antidepressant medication during the entire 84-day [12-week] acute treatment phase). In 2008, the PQRI list of indicators was expanded to 134 items, with two additional indicators related to the treatment of depression (percentage of patients aged ≥18 years of age with a new diagnosis or recurrent episode of MDD who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified; percentage of patients ≥18 years of age with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit). While the current PQRI indicators related to depression have only referred to the adequacy of assessment and treatment duration, a future version of the PQRI list of indicators may include a determination of the effectiveness of treatment. This will require clinicians to measure outcome using a reliable and valid measurement tool. The two surveys of current clinical practice by Gilbody and colleagues.10 and Zimmerman and McGlinchey11 suggest that educational efforts will probably be required to acquaint psychiatrists, as well as other healthcare professionals, with reliable, valid measures that are feasible to incorporate into clinical practice.

Recently, the term “measurement-based care” has been coined in reference to the use of standardized scales to measure the outcome of psychiatric treatment. Suggestions of the beneficial impact of measuring outcome come from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, the largest study of the treatment of depression ever conducted. In the acute phase component of STAR*D, during which patients were treated with citalopram for up to 12 weeks, the rates of response and remission were similar to the rates typically reported in controlled efficacy studies. Trivedi and colleagues30 suggested that an adequate treatment response might have been more difficult to achieve in STAR*D than typical industry-funded efficacy studies because patients with comorbid disorders, who are less responsive to treatment, were not excluded. They attributed the better than expected (albeit modest) response and remission rates to the adoption of a system of measurement-based care. That is, they suggested that the use of frequent, standardized, quantitative assessments to guide treatment decision-making contributed to an increased likelihood of a positive outcome, and they recommended that a measurement-based care approach toward clinical management be adopted in routine clinical practice. If measurement-based care is to be incorporated into clinical practice it will be important to keep the burden of that assessment to a minimum.



A consumer-friendly reliable and valid self-administered questionnaire can improve the efficiency of the clinical encounter, and allow clinicians to spend more time discussing topics other than symptoms. In this era when many clinical encounters are 15-minute (or briefer) medication visits, increased efficiency can make the visit more meaningful and beneficial to both clinicians and patients. The brevity of the CUDOS lends itself to regular administration in clinical practice. Although brief, it covers the full range of DSM-IV criteria and thus provides clinically useful information.

There may be only limited data suggesting that measurement might improve outcome when treating depression, but there is no reason to wait until the studies have been conducted to prove the benefit of measurement-based care in the treatment of depression. There is little downside to adopting this approach when treating depressed patients.

There are many self-administered depression scales, though some are less appealing as outcome tools for use in routine clinical practice because they are either too long,20-22 lack adequate coverage of the DSM-IV criteria,31,32 are expensive to purchase,19 or are somewhat complicated to score.31 Because of ease of use considerations, the authors recommend that either the CUDOS or the 9-item Patient Health Questionnaire (PHQ-9)33 be used by clinicians at every visit to monitor the course of depression. In fact, because it contains fewer items than the CUDOS, the PHQ-9 probably takes even less time to complete. However, the advantage offered by being somewhat briefer is offset by some loss of information. The PHQ-9 adheres to the construction of the DSM-IV criteria; thus, compound DSM-IV criteria that refer to more than one symptom (eg, insomnia or hypersomnia, increased or decreased appetite) are represented by a single item on the PHQ-9. Since treatment decision making might be influenced by whether a patient has insomnia or sleeps too much, or has a reduced appetite or eats too much, the PHQ-9 does not capture potentially clinically significant information. However, more important than which scale is used to monitor outcome is that some measure is used. Measures such as the CUDOS or PHQ-9 have clearly identified cutoff scores to identify remission and should not require any special training to be adopted by non-mental health professionals.

Upon reading this article, many clinicians are likely to persist in not using standardized scales to measure outcome when treating depression. The authors of this article hope to hear from clinicians as to why they have not changed their behavior. Please send us an e-mail. As mental health professionals, the authors are well aware of the difficulty of getting individuals to change their behavior. Attempts to get patients to change behavior is not limited to mental health professionals. Readers who do not adopt a measurement-based approach toward treating depression should reflect on their reasons for not changing their behavior the next time they feel frustrated with a patient who does not follow their valid and appropriate treatment recommendations. PP



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23.    Zimmerman M, McGlinchey J. Depressed patients’ acceptability of the use of self-administered scales to measure outcome in clinical practice. Ann Clin Psychiatry. In press.
24.    Guy W. ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: National Institute of Mental Health; 1976.
25.    Zimmerman M, Posternak M, Chelminski I. Using a self-report depression scale to identify remission in depressed outpatients. Am J Psychiatry. 2004;161(10):1911-1913.
26.    Lambert MJ, Whipple JL, Smart DW, Vermeersch DA, Nielsen SL, Hawkins EJ. The effects of providing therapists with feedback on patient progress during psychotherapy: are outcomes enhanced? Psychother Res. 2001;11(1):49-68.
27.    Lambert MJ, Whipple JL, Vermeersch DA, et al. Enhancing psychotherapy outcomes via providing feedback on client progress: a replication. Clin Psychol Psychother. 2002;9(2):91-103.
28.    Lambert MJ, Hansen NB, Finch AE. Patient-focused research: using patient outcome data to enhance treatment effects. J Consult Clin Psychol. 2001;69(2):159-172.
29.    US Department of Health and Human Services. Physician Quality Reporting Initiative. Center for Medicare and Medicaid Services. Available at: www.cms.hhs.gov/PQRI/30_EducationalResources.asp. Accessed April 23, 2008.
30.    Trivedi M, Rush A, Wisniewski S, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. Am J Psychiatry. 2006;163(1):28-40.
31.    Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12(1):63-70.
32.    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psych Meas. 1977;1(3):385-401.
33.    Kroenke K, Spitzer R, Williams J. The PHQ-9. Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.


Dr. Bodkin is project director for the Center of Prevention and Evaluation (C.O.P.E.) in the Department of Psychiatry at Columbia University at the New York State Psychiatric Institute in New York City. Ms. Singh is graduate student in the masters program for Clinical Psychology at Teacher’s College at Columbia University. Dr. Corcoran is Florence Irving assistant professor of clinical psychiatry and director of C.O.P.E.

Disclosure: Dr. Bodkin and Ms. Singh report no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Corcoran receives research support from the National Institute of Mental Health.

Please direct all correspondence to: Cheryl Corcoran, MD, Director, Center of Prevention and Evaluation, New York State Psychiatric Institute, 1051 Riverside Dr, Room 4804, New York, NY 10032; Tel: 212-543-6177; Fax: 212-543-6176; E-mail: cc788@columbia.edu.





Smoking cannabis is common among adolescents and young adults and has numerous negative effects. This article describes data which support the hypothesis that cannabis may induce psychotic symptoms and contribute to the onset of psychotic disorders, specifically in a vulnerable subset of youths. This vulnerability, which consists of genetic variation and which may be manifest in particular behaviors and experiences, including schizotypy, is explored. Possible motivations for use among vulnerable teenagers are discussed, the understanding of which may inform treatment efforts by clinicians to curtail use. As various psychotherapies appear equally effective in reducing cannabis use in comparable populations, there may be a nonspecific component consisting of clinician contact and education which may be of use to nonspecialists in addressing cannabis abuse.



According to the National Institute on Drug Abuse, cannabis, or marijuana, is the most widely used illegal drug in the United States.1 Nearly 45% of teenagers in the US have smoked cannabis before graduation from high school. Numerous adverse consequences of cannabis use by teenagers have been described, including difficulties with problem-solving, memory, learning, judgment, and perception.2,3 These problems in thinking can interfere with academic, social, and athletic performance as well as aggravate risk-taking behaviors, including having unprotected sex and driving recklessly.1 There are also medical consequences for cannabis use in youths, including immunosuppression, coughing and wheezing, and a greater risk of pneumonia.1 In terms of exposure to cancer-causing chemicals, it has been estimated that smoking five joints of marijuana/day may be equivalent to smoking one pack of cigarettes.4 In addition, cannabis use can lead to anxiety, feelings of paranoia, and perceptual disturbances.1

In reviewing the evidence from many studies, some investigators have concluded that, in fact, cannabis use can lead in some youths to the development of psychotic disorders such as schizophrenia.5,6 It has been estimated that cannabis use accounts for 1–2 new cases of schizophrenia for every 100 individuals annually7 and that 8% to 13% of all cases of schizophrenia can be attributed to cannabis use (ie, attributable risk).8 Of note, this percentage is larger than the 5.5% associated with genetic risk for schizophrenia, ie, having an affected first-degree relative.9 Whereas a teenager cannot change who his or her parents or siblings are, smoking cannabis is a behavior that potentially can be modified.

This article describes evidence that cannabis may contribute to psychotic symptoms and disorders, particularly in a subset of vulnerable youths, and reviews their possible motives for use of cannabis. The article also discusses the ways psychiatrists on the front lines can address the problem of cannabis use.


Evidence that Cannabis Use May Increase the Risk for Psychotic Disorder

Much evidence shows that psychotic disorders and the use of drugs, especially cannabis, occur together more often than chance would predict. For example, schizophrenia patients have far higher rates of substance abuse or dependence (approximately 50%) than the general population (17%).10-12 It does not appear that the drug use is simply a consequence of having a psychotic disorder, ie, “self-medication” of symptoms, as up to 50% of youths experiencing a first episode of psychosis already have a diagnosis of substance abuse or dependence.13 Cannabis abuse and dependence are especially prevalent in first-episode psychosis patients (approximately 20% to 40%),13 particularly in adolescents.14,15 Retrospective studies of first-episode psychosis patients suggest that cannabis use almost always precedes the development of psychotic-like symptoms.16

The observed co-occurrence of cannabis use and psychotic disorder shows only that there is an association, however, and does not necessarily support the hypothesis that cannabis use can play a causal role in psychosis and psychotic disorders. However, three types of studies—prospective cohort, experience sampling, and challenge studies—provide evidence that, in fact, cannabis use may lead to psychosis, particularly in vulnerable individuals.


Prospective Cohort Studies

Prospective cohort studies follow a whole population or “cohort” over several years to determine if earlier exposures are associated with later outcomes. Relevant to this article, “cannabis use” is the “exposure” and “schizophrenia” is the “outcome”; in fact, several studies demonstrate the association of earlier cannabis use with later schizophrenia.5,6 In such studies, one must always be wary of potential “confounds,” ie, factors that are related both to the exposure and to the outcome. For example, an apparent association of “sunburn” with children not going to school can in fact be explained by the fact that both tend to occur during the summer months. In the case of cannabis use and schizophrenia, one can imagine that early “prodromal” symptoms of schizophrenia, which include odd thinking, social dysfunction, and symptoms of anxiety, might both herald a later onset of schizophrenia yet also contribute to the use of cannabis. When an association of cannabis use at 15 years of age and schizophrenia at 26 years of age was “adjusted” statistically for earlier “prodromal” symptoms at 11 years of age, the risk for schizophrenia was less but still statistically significant.8 This suggests that whereas prodromal symptoms might lead to cannabis use, they cannot fully explain the association of teen cannabis use with later schizophrenia. In this same “cohort” it was found that it was only among some teenagers that cannabis use predicted later schizophrenia, ie, those with a variation of a gene that regulates dopamine metabolism—specifically catechol-O-methyl transferase (COMT).17 This is especially relevant as dopaminergic circuits have been implicated in psychosis and schizophrenia.18


Experience Sampling Studies

Relevant experience sampling studies are those in which an individual, usually a college student, is prompted by a beep from a watch numerous times a day to answer questions about cannabis use and transient symptoms such as anxiety, perceptual disturbances, and feelings of suspiciousness. These transient symptoms are, of course, not equivalent to psychotic disorders per se, but an association in this short time frame would support the plausibility of a connection. In fact, cannabis use at one time point was found to be associated with anxiety and psychotic-like symptoms at the following time point (using “time-lag analysis”).19 By contrast, symptoms did not precede use, which works against the idea of simple self-medication. As with the prospective cohort studies, only some youths appeared to be vulnerable to developing psychotic-like symptoms in the context of cannabis use, in this case those identified as “prone” to psychosis.19


Challenge Studies

Relevant challenge studies are those in which an active ingredient of cannabis, delta 9 tetrahydrocannabinol (Δ9THC), is administered. Intravenous injection of Δ9THC leads in both healthy individuals and in schizophrenia patients to transient psychotic symptoms as well as anxiety, cognitive deficits, and negative symptoms.20,21 In another study,22 smoking of a cigarette containing Δ9THC led to psychotic symptoms only in those youths who have the same gene variant implicated in the aforementioned cohort study, namely COMT, especially in those individuals with psychosis proneness.

Although cannabis smoking does not typically induce psychotic symptoms in most normal individuals,23 it does transiently worsen psychotic symptoms in schizophrenia patients, an effect accompanied by changes in dopamine release, as evident from brain imaging.24 These challenge studies all support the notion that cannabis can induce psychotic symptoms, but primarily only in those with an existing vulnerability, either by virtue of genetic predisposition or by behavioral symptoms.



Prospective cohort studies suggest teenage cannabis use can lead to adult psychotic disorders in a subgroup of youths. Both experience sampling and challenge studies demonstrate that cannabis use can lead to transient psychotic symptoms, particularly in vulnerable individuals. Of note, such transient symptoms are not benign because among youths psychotic-like symptoms confer greater risk for later psychotic8,25 and substance abuse/dependence diagnoses.26


What Constitutes the Vulnerability to Psychotic Symptoms in the Context of Cannabis Use?

As mentioned, not all individuals develop psychotic symptoms in the context of cannabis use. In a survey of youths, only 14% described developing “strange, unpleasant experiences such as hearing voices or becoming convinced that someone is trying to harm them” after smoking cannabis.27 It is important for the general practitioner to understand what may characterize this subset of youths who have such experiences.


Genetic Differences/Family History

In both prospective cohort studies and challenge studies, a variation in a dopamine metabolism gene COMT appears to confer vulnerability to psychotic symptoms in the context of cannabis use.17,22 Although of interest in terms of biologic mechanisms, this finding has limited clinical use, as young patients do not routinely have genetic analyses. However, clinicians may have a good sense of whether a young person has a family history of psychosis, which is a proxy for genetic vulnerability. Interesting work conducted by Caton and colleagues28 shows that among dually diagnosed first-episode psychosis patients, those patients who go on to develop a primary psychotic disorder such as schizophrenia are more likely to have a family history of psychosis and worse premorbid functioning, possibly consistent with a prodromal period. Among youths identified as at heightened risk for schizophrenia by virtue of having two affected relatives, cannabis use is associated with psychotic-like symptoms at baseline29 and increased use of cannabis appears to precede the onset of a psychotic episode.30


Behavioral Features

In experience sampling studies, college students with “psychosis proneness” are more likely to develop both anxiety and psychotic-like symptoms (unusual perceptions and feelings of thought influence) in response to cannabis use, in contrast to normal college students who tend to find cannabis relaxing.19 Youths with these experiences and a specific variant of the COMT gene are especially likely to develop psychotic-like symptoms in the context of cannabis use.22 Psychosis proneness in these studies was assessed using an instrument called the Community Assessment of Psychic Experiences, a self-report questionnaire that probes the extent to which an individual has had unusual or psychotic-like experiences.19 A causal direction between cannabis use and psychotic-like symptoms in this vulnerable group is supported by time-lag analyses (in experience sampling studies)19 and randomization with placebo in challenge studies.22

Schizotypal symptoms, which overlap with “psychosis proneness,” may also constitute a vulnerability to psychotic symptoms in the context of cannabis use. “Schizotypy” is characterized by social withdrawal, psychotic-like symptoms, socio-emotional dysfunction, and odd behavior. In youths, these symptoms are associated with cannabis use31-34 and are themselves predictors of adult psychotic disorder.8 Although it is not clear whether the symptoms lead to the use, the use leads to the symptoms, or the causal association is “bidirectional,” it is nonetheless worthwhile for clinicians to pay special attention to cannabis use in youths with these sorts of characteristics.


Why Do Vulnerable Youths Smoke Cannabis if it Causes Psychotic-like Symptoms?

As there is enough evidence to support a causal role for cannabis in the development of psychosis in some youths, clinicians should regularly assess whether their teenage patients are using drugs. Attention should be especially focused on teenagers who have a family history of psychosis or who show signs of elevated risk, such as being socially awkward, having unusual ideas, and being socially isolated.

One step in helping these vulnerable adolescents and young adults to stop using cannabis is to understand why they use cannabis in the first place and what keeps them using it despite the potential negative effects it might be having on their mental state. It is possible their reasons for use are similar to those of other teenagers, but it is also possible that they use cannabis to cope with the emerging symptoms that are common among people at elevated risk for psychosis. Cannabis use may help them feel more at ease despite social anxiety. It may make them feel happier (less depressed) or just feel more deeply in general, as they may perceive an absence of feeling or disconnection from feeling. It may also help them feel as though they fit in with peers despite their awareness of being perceived as odd.

One candidate model for understanding cannabis use in vulnerable teenagers is the motivational model, which has been applied to substance use in the general population.35 Motivational models focus on motives for use, suggesting that people use drugs to achieve desired effects, which might include wanting to feel more comfortable with peers, wanting to feel less anxious or depressed, wanting to achieve a high, wanting to fit in, and/or having generally positive expectations about the feelings use will bring. Applying a motivational model to cannabis use in the population of youths at elevated risk would require studies on reasons for use. Motivations for cannabis use in vulnerable teenagers have not been studied, but this could be informed by research on motivations for use in teenagers in the general population.

Several common motivations for use of cannabis by teenagers have been identified, including enjoyment, fitting in, experimentation, social enhancement (such as feeling better in a social situation), boredom, relaxation, habit, activity enhancement, coping (with negative feelings), and altered perception (mind expansion; Table 1).36 Specific reasons for use may also reflect the presence of untreated or insufficiently treated symptoms and help the clinician in identification of youths at risk.


In a recent study37 that examined motives for cannabis use in 2,031 young Swiss adults, it was found that cannabis users who had coping motives for use were more likely to show symptoms of psychopathology, evidence more psychosocial distress, and endorse more distressing life events than those who had social motives. The authors suggested that secondary prevention for cannabis use should target young adults in the general population who report using cannabis in order to cope.

An examination of the literature on reasons for use raises many questions. Are the reasons for use that teens endorse truly motivations for use or are they rationalizations? Are the reasons they endorse consistent with the effects they experience? Are teens really aware of their reasons for use? Do their reasons change over time as they move from initial use to more frequent or heavy use? This again raises the issue of direction of causality in the association between cannabis and psychosis. Is it the symptoms that lead to use or does use itself cause the emerging symptoms, which may in turn lead to greater use, causing a vicious cycle?

An examination of correlates of cannabis use in teenagers muddies the picture further. Cannabis use and misuse by teenagers is associated with depression and anxiety38,39 mediated by psychosocial factors and stress exposure40-42; academic and functional decline38,40,42-44; and cognitive deficits,45 especially in attention.46 Teenage cannabis use is also related to suicidal behavior47 and premorbid psychopathology for personality, affective, and psychotic disorders.48

What the clinician can take from this research on reasons for use and the questions raised here is that vulnerable teenagers may have reasons for using cannabis that are similar to those of other teenagers. In addition, vulnerable teenagers may weigh the short-term benefits of use against the adverse effects that might come later and decide to use cannabis. This may be similar to what is seen for patients with established psychotic disorder, who report using drugs to cope, socialize, improve mood, reduce anxiety, and relieve boredom,35,49-54 despite admitted worsening of symptoms with use.35,49-52,54

Therefore, asking a vulnerable teenager why he or she uses cannabis may reveal a problem that can be addressed. In addition, discussing reasons for use provides an opportunity for the clinician to offer psychoeducation to vulnerable teenagers on the relatively higher risks of use for them as compared to their peers.


Interventions to Reduce Cannabis Use

There are no available data on effective treatments for cannabis use in vulnerable youths. Therefore, it may be useful to examine what interventions have been effective in reducing cannabis use in other groups, such as teenagers in the general population and patients with first-episode psychosis (Table 2). As for teenagers, little is known about the effectiveness of pharmacologic treatments for cannabis use,55 yet medications are unlikely to be useful given their poor track record in treating cannabis dependence in adults. Medications that have been studied in adults include bupropion,56,57 nefazodone,57,58 and divalproex sodium.59,60 Only rimonabant, a cannabinoid receptor antagonist, has been found to reduce the pleasurable effects of cannabis.61 However, it is not available in the US due to its association with such serious side effects as depression. Naltrexone actually increases cannabis’ pleasurable effects.58 In addition, no drug has been found to reduce consumption of cannabis (ie, oral THC).62


Psychosocial treatments for cannabis use may be more promising. There have been two randomized clinical trials of treatment for cannabis use, one of which focused specifically on young users.63-66 The Cannabis Youth Treatment project examined the benefit of five different psychotherapies for cannabis dependence and found that all five treatments led to improvement, although none were superior.63-66 The five treatments studied were motivational enhancement therapy, cognitive-behavioral therapy, family support network therapy, adolescent community reinforcement, and multidimensional family therapy. Motivational enhancement therapy focuses on reasons for seeking treatment and readiness for treatment as well as personal goals, self-efficacy, prior attempts to quit, and problems associated with cannabis use. Cognitive therapy includes skills training in drug refusal, social networking, time and anger management, problem-solving, anticipation of high-risk situations, and managing craving and relapses. Adolescent community reinforcement focuses on changing environmental contingencies related to cannabis use. Family support network therapy focuses on increasing family cohesion and providing parental support and education; it includes case management and home visits. Multidimensional family therapy emphasized family roles and interactions. As these interventions were all equally effective, it suggests that there may be some nonspecific component common to each of these that is helpful, such as clinician contact or psychoeducation. The good news in this is that no particular skill set or approach may be necessary for clinicians who want to help their young patients reduce cannabis use.

As mentioned, studies of treatments targeting cannabis use in young adults with psychotic disorder may also be useful to review in considering how to help vulnerable teenagers stop cannabis use. In one study,67 both specific cannabis-focused intervention and more general psychoeducation were found to lead to a statistically significant decrease in cannabis use by 3 months, an effect that continued 6 months beyond the end of treatment. Both groups reduced their cannabis use from a median of 4 days in the prior month (at baseline) to a median of 2 days in the prior month (at the end of 3 months of treatment), and then only 1 day in the prior month at follow-up. However, there was no concomitant improvement in symptoms or function.

Likewise, Addington and Addington68 found that the use of cannabis and other drugs by first-episode psychosis patients was reduced at 1 year after entry into an integrated psychosis treatment program, despite patients’ rejecting the added help of a group specifically devoted to reducing substance use. There were significant reductions in use of both cannabis and hallucinogens, although alcohol consumption was not decreased. The specialty “substance abuse” group was rejected by patients for numerous reasons, including their denial that they had a problem or their feeling that they could quit or manage on their own. Overall, in this comprehensive program, clinicians explained that people with vulnerability to schizophrenia have a “sensitive brain” and that certain environmental stressors could exacerbate symptoms; substance use was framed as a major stressor. The authors68 recognized that the cause for the reduction in substance use was unclear, and they speculated that it may have been due to attitudinal or developmental changes and/or an effect of the education and encouragement provided by staff. What all of these studies suggest is that what might be effective is simply psychoeducation, support, and encouragement. This is something all clinicians can offer.

Clinicians who encounter a seemingly vulnerable adolescent or young adult who may be smoking cannabis should consider the suggested guidelines in Table 3.69





Cannabis use is an important target for intervention with vulnerable youths, as its reduction may prevent the occurrence of psychotic-like symptoms and prevent (or delay) the onset of psychotic disorders, such as schizophrenia. Psychotic-like symptoms, even if they do not lead to a diagnosable disorder, are associated with many negative consequences. In the absence of preventing onset, even a delay in psychosis onset is a desirable goal, as a later onset of psychosis might enable a young person to consolidate academic, vocational, and social achievements and goals.

The vulnerability to psychosis among youths can be identified by examining their family history of psychotic disorders and by their behaviors and experiences, with vulnerability associated with social withdrawal, psychotic-like symptoms, socio-emotional dysfunction, and odd behavior. An absence of friends may be a particularly good sign of vulnerability.

The motivations for cannabis use among such vulnerable teenagers are poorly understood, though they may be similar to those identified both by teenagers in general and by young adults with a first episode of psychosis—essentially, to socialize, cope, feel better, relieve boredom, feel less anxious, and get high. Understanding motivations for use for any particular individual may be a useful first step in helping him or her stop or at least cut back on drug use.

Treatments to reduce cannabis use in vulnerable teenagers have also not been studied. However, numerous psychosocial treatments seem to help with reducing cannabis use by both teenagers in general and by youths with a first episode of psychosis. This suggests that some nonspecific element of these various treatments—listening, encouragement, or provision of education—may be useful in reducing use. These strategies do not require specific training and can be used by all clinicians. PP



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