The emotional distance imposed by videoconferencing (figure) can be offset by the psychiatrist’s adoption of a more energetic, expressive style. Remote access may actually benefit patients with abuse histories or concerns about confidentiality. Technical recommendations by Shore (p. 256) include closer framing of the clinician to increase the feeling of contact, minimizing the clinician’s gaze angle, and allowing for transmission delay. Telepsychiatry mandates a low threshold to inquire about alcohol consumption and special attention to safety for patients videoconferencing from their homes. An emergency plan and procedures for filling prescriptions and doing laboratory tests should be determined before meetings begin. The Center for Medicare and Medicaid Service has established “privileging by proxy” for telehealth practice, but some individual states and malpractice insurance carriers have additional requirements.

The only dietary or psychological treatments that improve core symptoms of attention deficit hyperactivity disorder (ADHD) are supplementation with omega-3/omega-6 free fatty acids and elimination of artificial food colorings. Even these effects are small, limited to food-sensitive individuals, or dependent on coadministration of medication. Other meta-analyses by Sonuga-Barke et al. (p. 275) of blinded studies provided no evidence of improvement from cognitive training, neurofeedback, behavioral interventions, or exclusion of foods associated with hypersensitivity. However, Galanter notes in an editorial (p. 241) that behavioral treatments may improve symptoms of co-occurring conditions or behaviors specific to the home.

The cluster of cardiovascular and diabetes risk factors known as metabolic syndrome is twice as common among patients with bipolar disorder as among the general population. Antipsychotic medication and greater age further increase the rate. Vancampfort et al. (CME, p. 265) recommend multiple measurements of waist circumference or body mass index, blood pressure, and fasting levels of glucose, lipids, and cholesterol during the first year of treatment. Patients with risk factors should be encouraged to exercise, make dietary changes, and stop smoking. If lifestyle interventions do not succeed, switching to a lower-risk medication or adding one that reduces weight or metabolic abnormalities may be indicated.