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- Growing Awareness of Allergy Anxieties Spur Mental Health Visits
The rising incidence of food allergies among children over the past decade appears to have been accompanied by a growing awareness among pediatric allergists that their patients may need mental health care to manage anxiety related to allergies, new research shows. From 2013 to 2023, referrals from pediatric allergists to mental health experts related to food allergies rose 11-fold at one children’s hospital system. Referrals in 2023 were 50% higher than in the period between 2018 and 2022, researchers reported at the 2024 annual scientific meeting of the American College of Allergy, Asthma and Immunology. “I hope this [study] increases awareness for pediatricians and allergists to discuss anxiety with families,” said David Stukus, MD, director of the Food Allergy Treatment Center at Nationwide Children’s Hospital in Columbus, Ohio, who helped conduct the research. “It is important to normalize this as much as possible as some people may see anxiety as a negative stigma.” Stukus and his colleagues said their study was not designed to draw conclusions about the incidence of pediatric anxiety linked to food allergies. “Our study was only designed to evaluate the number of referrals over time, and we observed a significant increase in referrals,” he said. “Our study was not designed to assess why or to evaluate if anxiety was increasing among all of our patients or the population of children with food allergy at large.” Clinicians and researchers now have a better understanding that anxiety is a component of having food allergies, “but I am not aware if anxiety itself has been increasing or we are simply more aware to assess for it and ask about it,” he said. The center was opened in 2021, and two psychologists were hired to help families and children dealing with anxiety in relation to allergies, Stukus said. His team conducted the study to characterize the use of the new psychology services. Stukus and his colleagues conducted a chart review of 250 referrals (141 male; median age, 9.5 years) to outpatient pediatric psychologists at Nationwide Children’s Hospital. The data included demographic information, medical history related to food allergies, and the number of psychology appointments. The findings revealed that 88% of patients were referred for psychological assessment owing to concerns related to food allergies, with 69% of the children exhibiting symptoms of anxiety related to their food restrictions. More than 50% had prior documented anaphylaxis. Of those referred, 60% followed through with at least one appointment, and on average, patients attended 5.5 follow-up appointments in the following year. Although awareness of the psychological impact of food allergies is growing, Stukus said not enough psychologists and therapists are available to help children. “And even those that are, they don’t necessarily have the background specific to food allergies and anxiety pertaining to those,” Stukus said. Zachary Rubin, MD, a pediatric allergist and immunologist at Oak Brook Allergists in Elmhurst, Illinois, said food allergies can play a large part in the mental health of patients. “When you have to constantly think about what you’re eating to make sure that it’s safe to consume and not have a severe allergic reaction, that can create a lot of problems psychologically,” Rubin said. “It is a chronic disease.” Kari Benson, PhD, a pediatric psychologist at Nationwide Children’s Hospital , said pediatricians usually refer patients to her when the anxiety begins to interfere with their day-to-day lives. “The kids have been avoiding eating lunch with their friends at school, maybe they only feel comfortable eating privately at their own table or at the allergen-free table, or maybe they won’t go to friends’ houses,” Benson said. “Or maybe they’re not necessarily avoiding anything but just that they spend a lot of their day worrying, and it’s really just having an impact on mood and stress.” Note: This article originally appeared on Medscape .
- Can Weight Loss Drugs Also Treat Addiction?
A new study provides more evidence that glucagon-like peptide 1 receptor agonists (GLP-1 RAs) used to treat diabetes and obesity could be repurposed for opioid use disorder (OUD) and alcohol use disorder (AUD). Researchers found that patients with OUD or AUD who were taking semaglutide (Ozempic, Novo Nordisk) or similar medications for diabetes or weight-related conditions had a 40% lower rate of opioid overdose and a 50% lower rate of alcohol intoxication than their peers with OUD or AUD who were not taking these medications. Their real-world study of more than 1 million adults with a history of OUD or AUD provide “foundational” estimates of the association between glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA prescriptions and opioid overdose/alcohol intoxication “and introduce the idea that GLP-1 RA and other related drugs should be investigated as a novel pharmacotherapy treatment option for individuals with OUD or AUD,” the investigators led by Fares Qeadan, PhD, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois, wrote. The study was published online on October 17 in the journal Addiction . Protective Effect? As previously reported by Medscape Medical News, earlier studies have pointed to a link between weight loss drugs and reduced overdose risk in people with OUD and decreased alcohol intake in people with AUD. Until now, most studies on GLP-1 RAs and GIP agonists like tirzepatide (Mounjaro) to treat substance use disorders consisted of animal studies and small-scale clinical trials, investigators noted. This new retrospective cohort study analyzed de-identified electronic health record data from the Oracle Health Real-World Data. Participants, all aged 18 years or older, included 503,747 patients with a history of OUD, of whom 8103 had a GLP-1 RA or GIP prescription, and 817,309 patients with a history of AUD, of whom 5621 had a GLP-1 RA or GIP prescription. Patients with OUD who were prescribed GLP-1 RAs had a 40% lower rate of opioid overdose than those without such prescriptions (adjusted incidence rate ratio [aIRR], 0.60; 95% CI, 0.43-0.83), the study team found. In addition, patients with AUD and a GLP-1 RA prescription exhibited a 50% lower rate of alcohol intoxication (aIRR, 0.50; 95% CI, 0.40-0.63). The protective effect of GLP-1 RA on opioid overdose and alcohol intoxication was maintained across patients with comorbid conditions, such as type 2 diabetes and obesity. “Future research should focus on prospective clinical trials to validate these findings, explore the underlying mechanisms, and determine the long-term efficacy and safety of GIP/GLP-1 RA medications in diverse populations,” Qeadan and colleagues concluded. “Additionally, the study highlights the importance of interdisciplinary research in understanding the neurobiological links between metabolic disorders and problematic substance use, potentially leading to more effective treatment strategies within healthcare systems,” they added. Questions Remain In a statement from the UK nonprofit Science Media Centre, Matt Field, DPhil, professor of psychology, The University of Sheffield, Sheffield, England, noted that the findings “add to those from other studies, particularly animal research, which suggest that this and similar drugs might one day be prescribed to help people with addiction.” However, “a note of caution is that the outcomes are very extreme instances of substance intoxication,” added Field, who wasn’t involved in the study. “Those outcomes are very different from the outcomes used when researchers test new treatments for addiction, in which case we might look at whether the treatment helps people to stop taking the substance altogether (complete abstinence), or if it helps people to reduce the amount of substance they consume, or how often they consume it. Those things could not be measured in this study,” he continued. “This leaves open the possibility that while Ozempic may — for reasons currently unknown — prevent people from taking so much alcohol or heroin that they overdose and end up in hospital, it may not actually help them to reduce their substance use, or to abstain altogether,” Field said. The study had no specific funding. The study authors and Field declared no relevant conflicts of interest. Note: This article originally appeared on Medscape .
- Benzodiazepine Overprescribing Remains a Problem Post-Stroke
TOPLINE: About 5% of people older than 65 years in the United States are prescribed benzodiazepine after acute ischemic stroke (AIS) despite warnings of potential side effects in older adults, a new study shows. Although the findings indicate a slight decrease in benzodiazepine use for post-stroke anxiety (PSA) over the past decade, investigators say overdiagnosis remains a problem. METHODOLOGY: Researchers analyzed a sample of US Medicare claims from April 2013 to September 2021. A total of 126,050 beneficiaries (mean age, 78 years; 54% women; 82% White) discharged alive following an AIS were included. Patients previously prescribed benzodiazepine and those with self-discharge or discharge to skilled nursing facilities were excluded. Researchers assessed the demographics and comorbidities of patients, initial prescription lengths, cumulative incidence of first fills of benzodiazepine within 90 days post-discharge, and geographic and yearly trends. TAKEAWAY: Within 90 days of discharge, 5% of stroke survivors were initiated on benzodiazepine, with lorazepam (40%) and alprazolam (33%) prescribed most often. Most (76%) of first-time benzodiazepine prescriptions had a supply of > 7 days, with 55% covering 15-30 days. Women had higher initiation rates than men (6% vs 4%), and Hispanic adults had a higher cumulative incidence (6%) than adults of other ethnicities. Prescription rates were the highest in the Southeast (5%) and lowest in the Midwest (4%), with a slight countrywide decline (cumulative incidence difference, 1.6%) during the study period. IN PRACTICE: “Despite declining trends in benzodiazepine prescriptions, it is necessary to note that use remains alarming in the United States as it represents the third most used illicit or prescription drug in the country,” the authors wrote. Authors of an accompanying editorial noted that ideally, patients with stroke would be screened for PSA at discharge to allow for early diagnosis and appropriate treatment. “Unfortunately, access to mental health services after stroke can be limited, and not all hospitals or clinics will have these types of resources available,” the authors wrote. “These limitations require stroke physicians to often become the first line of treatment for PSA and sometimes are the only option available.” Note: This article originally appeared on Medscape .
- Psychiatrists Utilizing Ketamine-Assisted Psychotherapy
Psychiatrists are trying our ketamine-assisted psychotherapy in their clinical practices. What do patients think of this treatment? FROM OUR READERS This article is a response to the article “Doing It Together: Ketamine-Assisted Psychotherapy in a Small Group” by Dinah Miller, MD. Excellent nuanced points made by Dinah Miller, MD. I am another doctor who utilizes ketamine-assisted psychotherapy (KAP) in her private psychiatry practice. I believe that for the most part, psychiatrists utilizing KAP come to the practice with curiosity and determination to try to help our patients who struggle chronically and who have, in most cases, tried myriad other pharmacological and sometimes interventional alternatives. I worked as a psychiatrist for over a decade before exploring this treatment modality. I was trained in KAP in 2020 and entered the training (a 5-day in-person retreat with didactic and experiential components) with a healthy dose of skepticism; even after training, it took me several months to conclude that I wanted to give this a try in my own practice. Almost 4 years later, I can say I am glad I went there. In my practice, 75% to 80% of patients have noteworthy benefit. While we have little evidence-based data regarding KAP for reasons Dr Miller described, we do have evidence that psychotherapy helps patients, and that the specific type of psychotherapy is less important than the therapeutic alliance. So to my mind, combining a good therapeutic alliance (in a safe and intentional setting, with ample preparation) with the generic form of a medicine we know to be helpful for depression is not a huge clinical or ethical leap; in fact, patients of mine who have done a Spravato protocol and then come to my practice for KAP report that compared with the Spravato REMS protocol, the KAP approach feels like a completely different and much-improved version of treatment. The biggest hurdle here is affordability; like Dr Miller I sit with my patients for the 3-hour sessions and most insurance companies will only reimburse very minimally, if at all, for this non-FDA approved version of ketamine treatment. Note: This article originally appeared on Psychiatric Times .
- New Hope for Rapid-Acting Depression Treatment
Depression symptoms can be hard to manage, especially for people with treatment-resistant depression, a persistent and severe form of the disorder. Fortunately, new therapies are emerging for such hard-to-treat conditions. One of these is the medication ketamine, which numerous NIMH-funded studies have shown has fact-acting and lasting effects in people with mood disorders like depression. The discovery of ketamine has been a game changer for people with severe depression, who often need rapid relief from life-threatening symptoms. Whereas most antidepressants take weeks or months to work, ketamine works within hours to strongly reduce depression symptoms in people for whom other treatments have not worked. Despite ketamine’s effectiveness as an antidepressant, serious concerns limit its use, including problematic side effects and a high risk of misuse. To address these concerns, the National Institutes of Health (NIH) is invested in finding medications that capitalize on the therapeutic effects of ketamine while avoiding its negative ones. What did the researchers look at in the study? New research funded through the NIH Blueprint Neurotherapeutics Network for Small Molecules program examined a novel ketamine-related medication known as RR-HNK. RR-HNK is a metabolite , or byproduct, of ketamine left over as the body breaks it down. RR-HNK showed antidepressant effects in preclinical studies with animals , but it had not yet been tested in humans. The study involved a broad collaboration of researchers in the intramural programs at NIH’s National Institute of Mental Health , National Center for Advancing Translational Sciences, and National Institute on Aging; the Duke University and the University of Maryland School of Medicine; and other national and international institutions. What did the researchers do in the study? This study examined the safety, tolerability, pharmacokinetics (how the drug moves through the body), and pharmacodynamics (how the drug affects the body) of RR-HNK for the first time in humans. Participants were healthy adults between 18–65 years. A total of 74 people participated across three randomized trials: 55 received RR-HNK and 19 received an inactive placebo. Both the medication and placebo were given intravenously, with participants and researchers unaware of which group the participants were in. In Trial 1, participants received one of six dose levels of RR-HNK a single time. In Trial 2, participants received one of two dose levels of RR-HNK four times over 2 weeks. In Trial 3, participants received a single dose of RR-HNK, and their cerebrospinal fluid (a liquid surrounding the brain and spinal cord) was collected. The study's primary aim was to determine if the medication is safe by first testing it in healthy adults without a diagnosed mental health condition. Throughout the study, the researchers closely monitored for adverse events, such as negative side effects. The comprehensive safety profile included physical examinations; laboratory results; vital signs; electrocardiograms of heart activity; and ratings of mood, suicide risk, and dissociation and sedation symptoms. Additionally, participants were asked to tell study staff if they experienced any concerns or side effects at any point. The researchers also collected blood and urine samples from all participants before, during, and after receiving the medication. These samples and the cerebrospinal fluid collected in Trial 3 were used to check whether the medication entered the body and the brain. As a final exploratory step, the researchers used brain imaging to examine participants’ gamma oscillations (a type of brain wave) before and after the medication. This measure of the brain’s response to stimuli is one of the few available biomarkers of a medication’s effects on the brain. What did the study find? RR-HNK revealed itself to be exceptionally safe, causing no serious adverse events and only mild side effects that resolved quickly without care. Participants also reported no symptoms of sedation or dissociation. The positive safety profile was maintained at all doses tested and after multiple doses. Together, the results indicate that RR-HNK is safe and tolerable, with limited abuse or misuse potential. Cerebrospinal fluid confirmed that RR-HNK entered the brain and remained at detectable levels several hours after administration. Results further showed a dose-proportional response to the medication, meaning that at higher levels of RR-HNK, the amount of the substance in the body also increased at the same rate. A predictable relationship between the amount of RR-HNK given and the amount of RR-HNK in the bloodstream is important for the clinical efficacy of the medication, allowing doctors and researchers to accurately calibrate doses to a person’s specific level and type of symptoms. In the test of brain activity, some participants who received low to moderate doses of RR-HNK, but not those who received high doses or the placebo, showed an increase in the power of gamma oscillations. Preliminary evidence that RR-HNK produces a change in brain activity strengthens the case for its use as an antidepressant and provides a clinical biomarker for measuring whether it works in future research. However, there was large variability in the results and, given the small number of participants, the researchers caution against drawing firm conclusions from these findings. What do the results mean? This study offers critical insight into the safety, tolerability, and effects of RR-HNK in a diverse population of healthy adults. Findings from this early stage study demonstrate that the ketamine metabolite does not cause ketamine’s negative side effects and is safe for use in humans. The results also help set dosing parameters for its use in future research and treatment. These data, particularly a strong safety profile, support the progression into the next phase of research aimed at developing new therapies for people with hard-to-treat mental disorders. Despite the small size of each trial, which makes it difficult to interpret some of the results, the findings hold promise for the future of mental health treatment. This study is a critical early step in NIMH’s mission to improve the treatment of mental illnesses through research, setting the stage for clinical trials that test whether RR-HNK effectively treats depression and other disorders. Note: This article originally appeared on NIMH .
- List of Famous Psychoanalysts - origin of therapy
List of Famous Psychoanalysts - origin of therapy List of Famous Psychoanalysts - origin of therapy What is Psychoanalysis? Psychoanalysis , method of treating mental disorders, shaped by psychoanalytic theory, which emphasizes unconscious mental processes and is sometimes described as “depth psychology.” The psychoanalytic movement originated in the clinical observations and formulations of Austrian psychiatrist Sigmund Freud, who coined the term psychoanalysis . During the 1890s, Freud worked with Austrian physician and physiologist Josef Breuer in studies of neurotic patients under hypnosis. Freud and Breuer observed that, when the sources of patients’ ideas and impulses were brought into consciousness during the hypnotic state, the patients showed improvement. Observing that most patients talked freely without being under hypnosis, Freud evolved the technique of free association of ideas. The patient was encouraged to say anything that came to mind, without regard to its assumed relevancy or propriety. Noting that patients sometimes had difficulty in making free associations, Freud concluded that certain painful experiences were repressed, or held back from conscious awareness. Freud noted that in the majority of the patients seen during his early practice, the events most frequently repressed were concerned with disturbing sexual experiences. Thus he hypothesized that anxiety was a consequence of the repressed energy (libido) attached to sexuality; the repressed energy found expression in various symptoms that served as psychological defense mechanisms. Freud and his followers later extended the concept of anxiety to include feelings of fear, guilt, and shame consequent to fantasies of aggression and hostility and to fear of loneliness caused by separation from a person on whom the sufferer is dependent. Freud’s free-association technique provided him with a tool for studying the meanings of dreams, slips of the tongue, forgetfulness, and other mistakes and errors in everyday life. From these investigations he was led to a new conception of the structure of personality: the id, ego, and superego. The id is the unconscious reservoir of drives and impulses derived from the genetic background and concerned with the preservation and propagation of life. The ego, according to Freud, operates in conscious and precociousness levels of awareness. It is the portion of the personality concerned with the tasks of reality: perception, cognition, and executive actions. In the superego lie the individual’s environmentally derived ideals and values and the mores of family and society; the superego serves as a censor on the ego functions. In the Freudian framework, conflicts among the three structures of the personality are repressed and lead to the arousal of anxiety. The person is protected from experiencing anxiety directly by the development of defense mechanisms, which are learned through family and cultural influences. These mechanisms become pathological when they inhibit pursuit of the satisfactions of living in a society. The existence of these patterns of adaptation or mechanisms of defense are quantitatively but not qualitatively different in the psychotic and neurotic states. Freud held that the patient’s emotional attachment to the analyst represented a transference of the patient’s relationship to parents or important parental figures. Freud held that those strong feelings, unconsciously projected to the analyst, influenced the patient’s capacity to make free associations. By objectively treating these responses and the resistances they evoked and by bringing the patient to analyze the origin of those feelings, Freud concluded that the analysis of the transference and the patient’s resistance to its analysis were the keystones of psychoanalytic therapy. Early schisms over such issues as the basic role that Freud ascribed to biological instinctual processes caused onetime associates Carl Jung, Otto Rank, and Alfred Adler to establish their own psychological theories. Other influential theorists, including some who introduced significant departures from Freudian theory or technique, included Melanie Klein, Karen Horney, Ronald Fairbairn, Harry Stack Sullivan, Donald Winnicott, Erich Fromm, Erik Erikson, and Heinz Kohut. At one time psychiatrists held a monopoly on psychoanalytic practice, but later nonmedical therapists also were admitted to psychoanalytic training institutes. Later developments included work on the technique and theory of psychoanalysis of children, pioneered by Klein and Anna Freud, Sigmund Freud’s daughter. The Freudian tripartite division of the mind into id, ego, and superego became progressively more elaborate, problems of anxiety received increasing attention, and explorations of female sexuality were undertaken. Psychoanalysis also found many extraclinical applications in other areas of social thought, particularly anthropology and sociology, and in literature and the arts. Source: Brittanica (2023)
- Electroconvulsive Therapy for the Treatment of Dementia Symptoms
Key Takeaways Dementia affects over 6 million U.S. adults, with incidence rising due to aging trends, doubling risk every 5 years post-65. ECT shows promise in managing dementia's behavioral symptoms, despite no FDA-approved treatments, with nonrandomized studies indicating symptom improvement. Retrospective analyses suggest ECT may improve neuropsychiatric symptoms without worsening cognitive function, supporting its potential use. Clinical considerations for ECT include consent, comorbidities, and airway management, emphasizing thorough evaluation of patient-specific factors. Dementia is among the most debilitating neurodegenerative disorders related to aging. More than 6 million adults in the United States have dementia, and both the prevalence and the incidence rates of dementia are expected to rise quickly because of aging trends. The risk of dementia doubles every 5 years after the age of 65 years, and this increases to almost 50% in adults 90 years or older. Individuals with dementia often experience both psychological and behavioral symptoms, including depression, agitation, irritability, apathy, hallucinations, and delusions. There are currently no treatments approved by the US Food and Drug Administration (FDA) to manage behavioral and psychological symptoms of dementia. Nonpharmacological behavioral interventions are often recommended, but these can be difficult to implement in a standardized way and require substantial resources. Electroconvulsive therapy (ECT) has been shown to be very effective as a treatment for severe depression (without dementia). Some clinicians have used ECT as a therapy in severe cases to manage behavioral and psychological symptoms of dementia . Here we review the evidence for the use of ECT to manage those symptoms. Randomized Trials For any proposed therapy or intervention, the gold-standard level of evidence comes from randomized, controlled trials. As of October 23, 2023, there were no completed randomized trials of ECT in patients with dementia. A list of clinical trials of ECT use in patients with comorbid depression and dementia is in the Table. An ongoing, multisite trial (NCT03926520) in which patients with dementia are treated with ECT and usual care proposes to enroll 50 patients and aims to be completed in 2024. There have been 2 prospective, nonrandomized (single group) trials of ECT in dementia that have been completed. In one of these studies, patients were enrolled prospectively and were all treated with ECT. This study (NCT01856010) enrolled inpatients with dementia complicated by severe agitation and aggression who did not benefit from either pharmacological or nonpharmacological interventions. Most of these patients (78.3%) exhibited significantly reduced agitation from baseline to discharge as measured by the Cohen-Mansfield Agitation Inventory, a common assessment of agitation in dementia. The neuropsychiatric inventory scores also significantly decreased from baseline to discharge, indicating an improvement in memory (P < .001). Further, the Clinical Global Impressions Scale scores changed from a rating of “markedly agitated/aggressive” at baseline to a rating of “borderline agitated/aggressive” at discharge. There was no change in functioning (daily living) before or after ECT. Five of 23 patients discontinued treatment, with 3 patients stopping due to adverse events (2 for confusion/delirium, 1 for atrial fibrillation) and 2 patients stopping due to poor clinical response. Another study (NCT02969499) recruited 33 individuals with dementia who were treated with ECT. In this study, patients exhibited improvement in neuropsychiatric functioning a week following a course of ECT and an improvement in agitation 8 weeks following ECT. There was no discernible worsening in cognitive functioning or dementia symptoms . Retrospective Analyses Many reports of the use of ECT for comorbid dementia and depression or for behavioral and psychological symptoms of dementia are in the form of a case series. Rao and Lyketsos reviewed the medical records of 31 patients with primary dementia who also experienced depression. Compared with before ECT, these patients had lower depression severity scores (12.3 points on the Montgomery-Åsberg Depression Rating Scale) and an overall improvement on the Folstein Mini-Mental State Examination (1.6 points; P < .02). One of the larger studies on the use of ECT in patients with depression and dementia was conducted using Medicare claims data. In this study, 145 patients who received ECT were matched to a control cohort (N = 415) with respect to age, sex, principal diagnosis, medical comorbidities, and baseline scores of activities of daily living. All patients were hospitalized initially and followed for up to 1 year after discharge. This study found that, among those with dementia who were admitted to the hospital for a psychiatric problem, all patients generally declined in their functional status following discharge. Those patients receiving ECT had more favorable summary scores of activities of daily living compared with the control cohort, although the effects were small. Of note, those receiving ECT did not experience a differential worsening in their cognitive function. This is in line with another recent retrospective study of ECT in 313 patients with baseline mild to moderate cognitive impairment, which showed an improvement in cognitive functioning as measured by the Montreal Cognitive Assessment. This finding concurs with an older report of 44 patients with mild cognitive impairment or dementia who underwent ECT and showed no worsening in cognitive deficits irrespective of preexisting cognitive status . Clinical Considerations Given the lack of effective therapies for the behavioral and psychological symptoms of dementia in those with mild cognitive impairment and the profound burden that these symptoms cause to patients and families, it is reasonable to use ECT in select cases. In each case, a thorough analysis of the potential benefits and risks of therapy needs to be conducted and discussed with consenting parties. A few clinical considerations are worth mentioning. First, the issue of consent is paramount. The laws governing consent for ECT are administered at the state level, which means requirements vary considerably across the United States. A thorough and legal consent process needs to be carried out prior to therapy initiation, including an appeal to judicial authorities where required. Careful consideration must be given to the level of cognitive impairment and how this affects the patient’s ability to consent, as well as to local laws and regulations. Second is the consideration of comorbid medical issues. Individuals with dementia and cognitive impairment are often advanced in age and have many medical comorbidities. For some older individuals of a frail medical status, an acute series schedule of 2 treatments per week (as opposed to 3 times per week) can allow for a more tolerable treatment course. Another consideration involves management of the airway. Sometimes patients with dementia have difficulty managing secretions. The judicious use of an anticholinergic medication (eg, glycopyrrolate) can help improve the safety of airway management during the periprocedural time. Concluding Thoughts Large database analyses of thousands of patients have essentially ruled out the possibility that ECT causes dementia. Further research involving smaller groups of patients with dementia or cognitive impairment has also supported the reassuring conclusion that ECT does not worsen baseline dementia or cognitive impairment. In fact, some data suggest an improvement in cognitive function following ECT. Where resources are available, where patient and family preferences and clinical considerations provide, and when potential benefits outweigh the risks, ECT can be considered in select cases to manage the behavioral and psychological symptoms of dementia. Note: This article originally appeared on Psychiatric Times .
- Low-Dose Lithium: A New Frontier in Mental Health Treatment
Key Takeaways Low-dose lithium shows promise in preventing dementia and reducing suicide risk, with evidence supporting its neuroprotective effects. Microdoses of lithium may address a potential deficiency, improving mood, irritability, and cognitive function. Lithium's role in addiction recovery includes reducing medication use and improving treatment outcomes. Research supports lithium's efficacy in treating resistant depression, with benefits observed even at lower doses. As a treatment, low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with reduced adverse effects. Rethinking Lithium Lithium has long remained at the forefront of effective treatments for bipolar disorder. However, due to safety concerns, a stigma often hangs over its use. For decades, data have slowly been building that lithium has a much wider dose-response curve with potential utility at lower doses. With my own patients, low and microdose lithium has been invaluable for helping with irritability, anger, and addiction. As a treatment, low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with reduced adverse effects. While not generally accepted as a nutrient, some authors have made strong arguments—based on animal research and ecological studies—that lithium may fit the definition of a mineral. This may help explain why microdoses of lithium are often helpful: patients may actually be struggling with a lithium deficiency. Arguably, the strongest evidence for low-dose or even nutritional doses of lithium is for the prevention of dementia and suicide. Recent research and my own clinical experience have demonstrated additional clinical applications, including for depression, substance use disorder, and irritability. Defying Cognitive Decline: How Low-Dose Lithium May Prevent Dementia Initial evidence for the effects of lithium on cognitive decline and dementia were uncovered in patients with bipolar disorder. Bipolar is well known to increase the risk of developing dementia. An analysis from 2020 found that a diagnosis of bipolar disorder tripled the risk. In contrast, studies on patients with bipolar disorder who were on lithium as a mood stabilizer found that lithium treatment significantly reduced the risk of dementia. Based on the findings, clinical trials started exploring the use of lithium as a direct treatment for Alzheimer disease. While some of the initial studies were mixed, further clinical trials have found benefits for slowing or halting the progression of cognitive decline with lithium treatment. A trial by Nunes et al even found potential benefits with 300 µg of lithium per day. At this microdose, patients with Alzheimer disease remained stable over 15 months as patients on placebo continued to decline. At the end of the study, Mini-Mental State Examination (MMSE) scores had dropped to 14 in the placebo group, whereas the lithium group held steady at just below 20. In 2011, a trial of low-dose lithium for cognitive decline also found benefits. Treatment included 12 months of low-dose lithium, with blood levels between 0.25-0.5 mmol/L. As compared with placebo, lithium-treated subjects had a decrease in phosphorylated tau in cerebrospinal fluid (CSF) and better cognitive function. After additional data was collected on the same subjects over the next 2 years, outcomes were further improved. Placebo patients worsened, whereas the patients on low-dose lithium remained mostly stable. Memory and attention were significantly better with lithium. Lithium also increased levels of amyloid-beta peptide in the CSF at 3 years. The increase was hypothesized to be due to an increased clearance of amyloid plaques with long-term lithium treatment. The final analysis of these patients was published in 2024. While a significant subset of patients had died, the patients who had received lithium had higher MMSE scores vs those who were given placebo: 25.5 vs 18.3, respectively. Verbal fluency testing also showed marked advantages with lithium treatment with scores of 34.7 vs 11.6. One of the most recent meta-analyses for patients with bipolar disorder found that pharmaceutical lithium reduces dementia risk by half. A separate meta-analysis of both the preclinical and clinical research found that lithium displays neuroprotective effects with clinical data showing positive results in patients with Alzheimer disease. Increasing cases of Alzheimer disease and dementia are one of the more sobering realities we face in medicine, as cases are projected to increase precipitously over the coming decades. Considering the challenges of our aging population, lithium may be a cost-effective augmentation strategy to fill treatment gaps for dementia prevention initiatives. A Life-Saver in Microdoses: The Potential of Lithium in Suicide Prevention Beyond the potential benefits for cognitive health, lithium may also be useful for another significant unmet need: suicide prevention . Suicide rates have been mostly on the increase in the United States since 2001. Suicide is the second leading cause of death among individuals aged 10 to 34. And while there is controversy around the research, in total, it strongly suggests that lithium has antisuicidal properties. Evidence for microdoses reducing suicide risks comes from a large and growing number of ecological studies exploring suicide rates and lithium levels in tap water. Lithium is naturally found in the environment, with tap water being a significant component of the lithium present in the diet. Tap water levels can vary dramatically from locality to locality providing natural variations in exposure. Lithium levels in drinking water are usually measured in micrograms per liter, suggesting that lithium may have relevant neurological effects even at these low levels. In 1970, the first report about lithium concentrations in tap water and local state mental health hospital admissions found an inverse correlation. As lithium exposure from groundwater increased, local hospital admissions were reduced. Over the ensuing decades, numerous research groups analyzed local water supplies and mental health outcomes, most often as suicide rates. A meta-analysis of this data was published in 2021, including 113 million individuals from 2678 regions around the world. The study found that higher groundwater lithium was correlated with reduced suicide and mental hospital admissions. Since the meta-analysis, most of the additional studies have continued to confirm the relationship. For patients with bipolar disorder, standard pharmaceutical doses of lithium have also shown consistent effects for lowering suicide risk. Tentatively, the results of the research suggest that lithium’s antisuicidal effects occur through a broad range of dosage levels. Considering the rising tide of suicides in this country and the safety of lithium when utilized in lower doses, lithium may deserve additional consideration as one component in a multiprong approach for suicide prevention . A Subtle Shift: The Promise of Low-Dose Lithium for Resistant Depression While the data shows that doses close to and including standard pharmaceutical levels are more effective for treating mania and depressive episodes in bipolar disorder , the research also has shown that lower doses are well-tolerated and may provide benefits in some cases of major depressive disorder. An open-label study in severely depressed patients who were unresponsive to an initial trial of venlafaxine found significant benefits with low-dose lithium augmentation. Lithium, at doses between 300 and 450 mg, does not require blood monitoring and was well tolerated. The authors argue that low-dose lithium may be a preferable first choice in “non-emergent situations'' due to its ease of use and higher tolerability. A separate, small, dose-response trial using lithium augmentation for treatment-resistant depression that was unresponsive to sertraline found that both 400 mg and 800 mg of lithium were equivalent in their clinical response. In patients with severe depression, a subset of patients on citalopram plus 300 mg of lithium carbonate achieved therapeutic blood levels and had significantly higher remission rates of suicidal thoughts. In patients with multiple sclerosis, low-dose lithium (between 150 and 300 mg) improved depression symptoms better than an observation period without lithium. However, not all research findings on low-dose lithium treatment for depression have found benefits. In patients on tricyclic antidepressants who were resistant to treatment, lithium at 750 mg provided significant benefits whereas doses of 250 mg did not. Breaking Chains: Lithium’s Role in Addiction Recovery Substance use and addiction are typically difficult to treat. Clinical trials are often plagued with high dropout rates, a predictor of relapse. As such, interpreting the data can be difficult. While the results are mixed, some research and my own clinical experience suggests that low-dose lithium may have a role for helping to treat addiction. An early study using an integrative medicine approach for treatment using 6 mg of lithium (as 150 mg of lithium orotate), combined with other supplements and dietary recommendations, found benefits for patients with alcohol use disorder. Of the treated patients who stayed on lithium, 36 of 42 had a history of hospitalization due to severe alcohol use. With lithium treatment, almost a quarter of patients remained alcohol free for up to 3 to 10 years. None of the patients needed additional hospitalizations. However, the study had numerous limitations, including a high drop-out rate and only included patients who managed to continue lithium treatment. In patients recently detoxed from alcohol, low-dose lithium (defined as blood levels between 0.3 and 0.5 mmol/L) or a vitamin placebo were administered. Due to a previous study noting that patients who detoxified from alcohol often displayed manic-type symptoms, the study was implemented to see if lithium could address these symptoms. For the detoxed patients on lithium, manic symptoms significantly decreased, fully normalizing over a 2-week period. For controls, manic symptoms did not significantly change and remained elevated. The most recent study of interest utilized 150 mg of lithium carbonate for patients at a residential addiction center as a replacement for antidepressants or benzodiazepine medications. With the implementation of low-dose lithium, opiate doses dropped by 50%, benzodiazepine use was almost eliminated, and atypical antipsychotics were reduced by more than two-thirds. Polypharmacy, or the use of 5 or more psychiatric medications in a treatment regimen, was reduced by almost 80%. For patients on lithium, program completion rates increased by almost 100%. In total, low-dose lithium effectively reduced medication use and improved residential addiction treatment outcomes. Cooling the Fire: Microdose Lithium for Anger and Irritability Irritability and anger are not official diagnoses in the DSM. As such, they are often considered as secondary to other conditions like depression or bipolar disorder and not treated directly. In children, disruptive mood dysregulation disorder (DMDD) encompasses problems with anger and irritability. From my own clinical experience, irritability often has roots in metabolic, environmental, and nutritional factors. While older studies on prison inmates suggest that lithium may have utility for decreasing anger and aggressive behaviors,30-32 in my experience, irritability is one of the most powerful indicators that a patient will benefit from low-dose or microdoses of lithium. For any patient struggling with irritability, especially when there is a family history of addiction, bipolar disorder , or depression, elemental lithium between 2 and 10 mg, typically as lithium orotate, has often provided significant relief. For children with DMDD, lithium can sometimes provide profound benefits, helping to safely decrease symptoms when used in such low doses. The Untapped Potential of Low-Dose Lithium Lithium has long had a starring role in standard medicine as a therapeutic option for bipolar disorder and as an adjunctive treatment for depression. Nonetheless, research and my own clinical practice with thousands of patients have found that lithium’s efficacy is still very relevant at lower doses. From an integrative medicine perspective, microdoses of lithium may act more like a nutrient,improving mood, reducing irritability, and supporting cognitive function. These low-dose benefits of lithium extend from hundreds of micrograms up through the standard dosage range of lithium used for bipolar disorder treatment . Note: This article originally appeared on Psychiatric Times .
- Therapeutic Needs and Inadequate Treatments
CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE This second of 5 articles addresses the kinds of therapeutic support needed to foster genuine resilience, the pressures (psychodynamic and economic/institutional) that impede the provision of such support, and the inadequate treatment offered in its place. Resilience Real and Factitious Resilience training is best informed by an understanding of how resilience naturally develops. For example, Abenes1 sees resilience as a buffer of mental fortitude that develops over time and can be modeled and nurtured by parents and other primary caregivers. With children and adolescents who are susceptible to psychiatric illnesses (70% of which manifest by the age of 24 years), an environment of safety, maintenance of healthy routines, and emotional regulation on the part of parents can help children regulate their own emotions. Resilience training in psychiatry, such as the program presented by “health experts” from Benson-Henry Institute for Mind-Body Medicine in 20222 and a lecture series offered by Massachusetts General Hospital,3 has the best chance of success when a therapeutic alliance has been established. Without the attachment and trust formed through a supportive alliance, the patient may not be able to release their defenses and incorporate the resilience-promoting factors that contribute to developing a robust and flexible capacity to maintain emotional stability during and after trauma. This restabilizing response can be understood as positive resilience, to distinguish it from a toxic form of resilience in which an individual recovers from trauma, but reactivates in the direction of a vengeful, hostile, and/or destructive (to themselves or others) goal.4 In clinical settings, patients who do not experience secure attachment and trust during what purports to be resilience training are at risk for developing a feigned or pseudo-resilience. That is, they decide to appear as if they have experienced a positive, resilience-promoting process or what they have been taught to manifest as recovery from psychiatric symptoms. They are observed to be no longer isolating or avoiding contact, but instead engaging well socially, expressing positive affect, eating well, sleeping well (by self-report), denying nightmares or suicidal or homicidal ideation, and engaging in creative activities. They essentially appear as if they have recovered fully and “bounced back” from the trauma or symptoms that led to their seeking or being referred for treatment, whether inpatient, residential, or outpatient. Appearances to the contrary, patients who are experiencing significant psychiatric symptoms usually do not develop the ability to return to the challenges of their lives, unmediated by structured treatment, after a few days of instruction in “cognitive reappraisal.” One of the most deceptive qualities that can underlie or support a superficial, misleading presentation of resilience is stoicism, which has been defined as a form of emotional and behavioral control that reflects an indifference to the vicissitudes of fortune and to pleasure or pain. Such a presentation can easily be mistaken for resilient qualities such as “grit and toughness” (as described in the previous article’s references to Tang et al). Although the concern for one’s appearance, reputation, or image that characterizes stoicism bears an external resemblance to resilience, it can mask what amounts to an unexploded emotional grenade. Sadly, inexperienced clinicians and trainees often have difficulty distinguishing the constricted affect of the stoic from the balanced affect of a genuinely resilient person. Lessons From Clinical Experience Given the complexities inherent in the development and manifestation of resilience, clinicians should be cautious in responding to a patient’s apparent resilience. As analyzed by Simon and Gutheil, a number of factors complicate an accurate assessment of the ongoing status of a patient undergoing psychiatric treatment after an attempted suicide or serious suicidal ideation . Patients who present as cognitively reconstituted still need to be assessed for disordered affective states that can impair their capacity for decision making and self-care. A patient who presents as ready for discharge may simply want to be free from the hospital, may wish to restart drugs, may have decided on a plan to complete suicide after discharge, or may believe mistakenly that he or she has truly improved as a result of the activating effects of medication, the supportive milieu, group therapy, improved sleep, or a “flight into health” (involving denial of ongoing symptoms). A stoic demeanor can contribute to such a misleading presentation. Moreover, some clinicians may avoid difficult questions or explorations because of cultural taboos or unexamined problematic feelings (their own or the patient’s) about suicide. This problem can result from the clinician’s subconscious or conscious discomfort in dealing with the issue of suicide or, not infrequently, from an unfounded concern that raising the issue of suicide with the patient will cause the patient to think more about committing suicide and then act on those thoughts. Such concerns add to pressures, including that created by the utilization review process,7-10 complicating staff reactions to patient presentations. These pressures have brought about a recent national movement among physicians to unionize out of concern that they cannot give their patients proper care in corporate environments (including hospitals, health insurers, and private equity) that now employ more than three-fourths of physicians in the United States.11-12 These pressures, both internal and external, may exert at least a subconscious influence on how staff focus on and process a patient’s presentation. Clinicians who feel pressure to view the patient's appearance, behavior, and interactions as positively as possible may overlook or minimize signs of ongoing illness or emotional instability. They may fail to ask directly about suicidality, fail to question the patient’s self-report of sudden improvement and denial of suicidal ideation, fail to seek communication with the patient’s collateral contacts to take into account relevant family dynamics and interpersonal interactions, or fail to share pertinent concerns. Instead, a misperception spreads among staff and clinicians that the patient’s apparent rapid recovery will be “durable enough to sustain the patient’s safety after discharge.” Meanwhile, the patient may be providing clues which, in the past, experienced clinicians usually have observed and reported, such as poor appetite, continued disheveled appearance, an absence of consistent social interaction with staff or peers, or an inability to trust, attach to, or develop a therapeutic alliance with clinicians. Other warning signs include possible delusions or self-dialoging and inconsistent compliance with medications (including possible “cheeking” of pills). Particularly concerning is the patient’s refusal to allow clinicians to speak with family or other collateral contacts, since “approximately 25% of patients at risk for suicide deny having suicidal ideation to their clinicians but do admit it to their families.” As pressure from the utilization review process grows, clinicians may not ask as often as they should whether the patient is having thoughts about self-harm or suicide. Thus, when the insurance reviewer asks whether the patient has expressed suicidal concerns, the clinician is able to say “no” because the question was not addressed recently, allowing the clinician, perhaps unconsciously, to collude with utilization reviewers and perhaps the patient in a contagion of “magical thinking” in which the patient is misperceived as significantly improved and “resilient.” As it becomes more and more challenging to resist the pressures for a shorter inpatient stay, it is all the more important for clinicians to examine possible urges, both external and internal, to perceive the patient as resilient in response to pressures from the patient, insurance companies, or the administration. As noted by Rufino, et al,14 citing a study by Appleby, et al, “the majority of deaths by suicide post discharge happened within the first week, with most suicides occurring the day after discharge: 186 of those suicides occurred before the initial follow-up appointment. In a comparable study, Bickley, et al, identified risk and protective factors for suicide among 100 psychiatric patients who died within 2 weeks post-discharge. Of these patients, 55% had died by suicide within the first week after discharge and 49% died before their first follow-up appointment.” As we continue to learn what factors can support and what factors can undermine resilience in all its complexity, we must remain alert to the risk of perceiving resilience that may in fact be either fragile or entirely absent, a misperception that can impede proper clinical care. Note: This article originally appeared on Psychiatric Times .
- Complex PTSD: A Necessary DSM Addition
Key Takeaways Complex PTSD is not formally recognized in DSM-5-TR, affecting clinical understanding and treatment development. Historical events, like the Vietnam War and women's rights movements, influenced PTSD's diagnostic evolution. Only two medications are FDA-approved for PTSD, highlighting the need for more treatment options. Clinicians should prioritize trauma screening and education to improve patient care and treatment outcomes. "This was a tragic exclusion,” wrote Bessel van der Kolk, MD, one of the world’s experts in posttraumatic stress disorder (PTSD), following the publication of DSM-IV in 1994 when it failed to include a new diagnosis of complex PTSD . Yet here we are, 30 years and 3 DSMs later, with no formal or professional recognition of complex PTSD as a very different disorder than what DSM-5-TR describes for PTSD. In fact, DSM-5-TR provides only 2 specifiers to further differentiate PTSD: PTSD with dissociative symptoms (depersonalization vs derealization) and PTSD with delayed expression (ie, “the full diagnostic criteria are not met until at least 6 months after the event”). This misstep has had a cascading impact on the lack of clinical understanding of the complexities and differences in symptoms that can result from the experience of different types of trauma. Additionally, it has created a cloud of confusion regarding the PTSD diagnosis , which in turn results in the lack of tools and treatments that should be utilized in subpopulations of individuals with varying trauma histories. Finally, the vagueness of the DSM’s characterization of trauma has likely prolonged the considerable unmet need of additional pharmacological treatments. It is possible that if the US Food and Drug Administration Advisory Board had a more comprehensive understanding of the effects of different types of trauma and the wide range of treatments that should be available, it would have reached a different conclusion when it recommended against approval of midomafetamine (MDMA)–assisted psychotherapy this past June. Notably, the 2 phase 3 studies submitted to the FDA primarily included individuals who likely would have met the diagnostic criteria for complex PTSD; all participants in one of the studies met the criteria for severe PTSD, and 73% of participants in the second. Exploring the Evolution of PTSD in Psychiatry In 1896, Sigmund Freud, MD, published “The Aetiology of Hysteria,”4 in which he hypothesized that hysteria was caused by the sexual abuse of children before the onset of puberty based on his analysis of 18 adult patients with hysteria who reported a history of childhood sexual abuse and incest; this became known as the seduction theory. When Freud presented this paper at Vienna’s Society for Psychiatry and Neurology, he received a cold reception from the audience. His colleague who presided over the presentation characterized the paper as “a scientific fairy tale.” Due to continued criticism from his medical and psychiatric colleagues, he publicly retracted the seduction theory by 1905. During World Wars I and II, millions were exposed to horrific warfare. Soldiers were particularly impacted and reported loss of memory and ability to feel. It was reported that during World War I, 40% of British battle casualties were due to “mental breakdowns.” Shell shock was the term used to describe what had caused the severe emotional distress of soldiers. Trauma expert Judith Herman, MD, wrote, “It was recognized for the first time that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure.”5 Herman further wrote about how “the lasting effects of war trauma were once again forgotten,” shortly after World War II. During the 1960s and 1970s, the Vietnam War facilitated an upheaval throughout the US after Americans witnessed via television the horrific nature of war and gained a growing awareness of the impact of these violent experiences on individuals. Veterans who were traumatized—often decorated war heroes—would not let us forget. Vietnam veterans organized groups to support one another. In 1970, psychiatrists met with a veteran-formed group called Vietnam Veterans Against the War and saw firsthand the effects of combat trauma exposure. Coinciding with the activism of the Vietnam veterans, the country also saw a new wave of the women’s rights movement. In 1970, the 50th anniversary of suffrage, people participated in the Women’s Strike for Equality, the largest women’s rights demonstration since suffrage. This demonstration raised national awareness on many issues related to women’s rights, health, safety, and equality. In 1973, the National Organization for Women (NOW) started the NOW Task Force on Rape, advocating for legal reform at the state level. The convergence of this activism likely had a significant impact on updating and revising 1968’s DSM-II. In 1980, DSM-III was introduced with the new diagnostic entity “posttraumatic stress disorder.” Significantly, PTSD was clustered under the category of “anxiety disorders” from 1980 until the publication of DSM-5 in 2013. It was then separated into a new category titled “trauma- and stress- or related disorders,” where it remains today. The Diagnosis of ‘PTSD’ Is Too Nonspecific With the DSM-III acknowledging the primary role of trauma in psychological distress, the symptoms of PTSD, and as a common etiological primary factor contributing to other psychiatric and medical comorbidities, trauma-related research exploded. Experts in trauma-related disorders, including van der Kolk and Herman, quickly recognized the limitations of a single and generally defined diagnosis for individuals’ experiences and the life-altering impact of those experiences, either immediately after the trauma occurred or decades later. In the early 1990s, van der Kolk was put in charge of a field trial by Robert Spitzer, MD, as revisions to DSM-III were being considered to produce DSM-IV. The field trial used a rating scale incorporating the many trauma symptoms found in the medical literature; the scale was administered during the interviews with 525 adult patient participants across the US. The goal was to investigate whether subpopulations with differing traumatic exposures demonstrated clinically different symptoms. The study populations included adult patients who had been physically or sexually abused in childhood by their caregivers, adult patients who were victims of recent domestic violence, and adult patients who had recently experienced a natural disaster. Significantly, the adults who had been abused in childhood by their caregivers demonstrated very different symptoms in adulthood than the other groups. A previous study by van der Kolk et al demonstrated that a history of sexual or physical abuse in childhood was a strong risk factor for recurrent self-cutting and suicide attempts later in life.8 The authors hypothesized that early-life severe trauma instills a feeling of lack of safety with others, leaving a lacuna in the structure of the self in contrast to the other subpopulations that had a template for feeling safe from long ago that could be accessed again through healthy adult relationships or therapy. Upon completion of this field trial, van der Kolk’s DSM-IV PTSD work group voted 19 to 2 to create a new diagnosis for patients with significant symptoms resulting from severe interpersonal trauma. They recommended the addition of the diagnosis “disorders of extreme stress, not otherwise specified,” also known as “complex PTSD,” to the DSM-IV.9-12 To their surprise and disappointment, their recommendation was ignored; no one in the PTSD work group was consulted. Conclusion The good news is that much progress has been made in developing evidence-based nonpharmacological treatments (Table 2). Although only 2 medications are approved by the FDA for treating PTSD (the selective serotonin reuptake inhibitors sertraline [Zoloft], approved in 1999, and paroxetine [Paxil], approved in 2000), 2 agents with very different mechanisms of action are in the review process. Garnering recent press is MDMA, which is meant to be used as part of structured medication-assisted psychotherapy; the FDA requested an additional phase 3 study. Brexpiprazole (Rexulti; FDA vote on approval is expected on February 8, 2025) is meant to be used as an augmentation agent for patients already on sertraline who only partially respond to treatment. As clinicians, we can and should educate ourselves further about the important and complex field of trauma and its treatment. Screening for past trauma in new and established patients is essential. It may take months, years, or even decades before our patients with a significant history of trauma, especially early-life trauma, develop enough trust to share their story with us. Yet past trauma is likely a contributing factor in many patients who present with anxiety, depression, substance use disorders, and many somatic complaints or diagnoses. The aforementioned book by van der Kolk1 comprehensively reviews what we have learned since 1980, and I highly recommend it as a good starting point. Often, our patients don’t know what to say or how to start to talk about their trauma. They are quietly waiting for us to begin the conversation. Note: This article originally appeared on Psychiatric Times .
- Smartphone Data Flag Early Dementia Risk in Older Adults
Older adults at risk for dementia can be identified using mobile data obtained during a wayfinding task, a novel real-world study suggested. During a smartphone-assisted scavenger hunt on a university campus, researchers observed that older adults with subjective cognitive decline (SCD) paused more frequently, likely to reorient themselves, than those without SCD. This behavior served as an identifier of individuals with SCD. "Deficits in spatial navigation are one of the first signs of Alzheimer's disease," study investigator Nadine Diersch, PhD, guest researcher with the German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany, told Medscape Medical News. This study, said Diersch, provides "first evidence of how a digital footprint for early dementia-related cognitive decline might look like in real-world settings during a short (less than 30 minutes) and remotely performed wayfinding task." The study was published online on October 3 in PLOS Digital Health . Trouble With Orientation Seventy-two men and women in their mid-20s to mid-60s participated in the study; 23 of the 48 older adults had SCD but still scored normally on neuropsychological assessments. All study participants were instructed to independently find five buildings on the medical campus of the Otto-von-Guericke-University Magdeburg, Magdeburg, Germany, guided by a smartphone app developed by the study team. Their patterns of movement were tracked by GPS. All participants had similar knowledge of the campus, and all were experienced in using smartphones. They also practiced using the app beforehand. In most cases, participants reached the five destinations in less than half an hour. The younger participants performed better than the older ones; on average, the younger adults walked shorter distances and generally did not use the help function on the app as often as the older ones. In the older adults, the number of orientation stops was predictive of SCD status. The adults with SCD tended to hesitate more at intersections. A decline in executive functioning might explain this finding, Diersch said. "Intact executive functioning is an important component of efficient navigation, for example, when switching between different navigation strategies or planning a route. However, since this was the first study on that subject, more research is needed to determine the precise contribution of different cognitive processes on digital wayfinding data," said Diersch. With more study, "we think that such a smartphone-assisted wayfinding task, performed in the immediate surroundings, could be used as a low-threshold screening tool — for example, to stratify subjects with regard to the need of extended cognitive and clinical diagnostics in specialized care," she added. 'A Game Changer' Commenting on the research, Shaheen Lakhan, MD, PhD, neurologist and researcher based in Miami, Florida, who wasn't involved in the research, said the findings have the potential to "revolutionize" dementia care . "We've seen smartphones transform everything from banking to dating — now they're set to reshape brain health monitoring. This ingenious digital scavenger hunt detects cognitive decline in real-world scenarios, bypassing costly, complex tests. It's a game changer," said Lakhan. "Just as we track our steps and calories, we could soon track our cognitive health with a tap. This isn't just innovation; it's the future of dementia prevention and care unfolding on our smartphone screens. We're not just talking about convenience. We're talking about catching Alzheimer's before it catches us," he added. The next phase, Lakhan noted, would be to develop smartphone apps as digital therapeutics, not just to detect cognitive decline but to treat or even prevent it. "Imagine your phone not only flagging potential issues but also providing personalized brain training exercises to keep your mind sharp and resilient against dementia," Lakhan said. This work was funded by the Deutsche Forschungsgemeinschaft (German Research Foundation) within the Collaborative Research Center "Neural Resources of Cognition" and a DZNE Innovation-2-Application Award. Diersch is now a full-time employee of neotiv GmbH. Lakhan had no relevant disclosures. Note: This article originally appeared on Medscape .
- New Treatment Effective for Male Postpartum Depression
A psychosocial intervention designed to improve depressive symptoms and promote good parenting skills can be an effective way of treating male postpartum depression, according to new research. In a study conducted in Pakistan, about 70% fathers with postpartum depression who received the intervention showed complete remission of their depressive symptoms and experienced enhanced relationships with their children and domestic partners. Called Learning Through Play Plus Dads (LTP + Dads), the intervention, which can be delivered by community health workers, could improve paternal mental health and child development not only in Pakistan but also in other populations, the authors stated. The results of the study were published on October 2 in JAMA Psychiatry . Stigmatized and Understudied "Pakistan is a patriarchal society with strict gender roles, and male mental health, particularly postpartum depression in new fathers, is stigmatized and understudied," lead investigator Ishrat Husain, MD, a senior scientist at the Centre for Addiction and Mental Health and associate professor of psychiatry at the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News. "Historically, and rightly so, the focus has always been on the mother, but men also experience significant emotional challenges as they adapt to being a parent. Fathers are also in need of support," said Husain. Male postpartum depression is prevalent in all populations. Globally, about 10% fathers have postpartum depression. But in societies like Pakistan, rates of male postpartum depression have been reported to be as high as 23.5%. The study included 357 fathers aged 18 years or older (mean age, 31.44 years) with a Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, diagnosis of major depressive episode and a child younger than 30 months. They were randomly assigned either to receive treatment as usual (n = 186) or to participate in the LTP + Dads program (n = 171). LTP + Dads is a parenting and mental health initiative adapted from a similar program for Pakistani mothers. It combines parenting skills training, play therapy, and cognitive behavioral therapy. In this study, the initiative was delivered by community health workers in 12 group sessions over 4 months. Sessions took place weekly for the first 2 months and biweekly thereafter. The researchers assessed changes in the 17-item Hamilton Depression Rating Scale (HDRS-17) score at 4 months and at 6 months. They also looked at anxiety symptoms; parenting stress; intimate partner violence; functioning; quality of life; and child social, emotional, and physical health outcomes. Improved Child Development There were significantly greater reductions in HDRS-17 scores in the LTP + Dads group than in the treatment as usual group at 4 months (group difference ratio [GDR], 0.66; P < .001) and at 6 months (GDR, 0.67; P < .001). Similar results were seen for anxiety (GDR, 0.62; P < .001), parenting stress (GDR, −12.5; P < .001), intimate partner violence (GDR, 0.89; P = .05), disability (GDR, 0.77; P = .03), and health-related quality of life (GDR, 12.7; P < .001) at 4 months. The differences in depression and parenting stress were sustained at 6 months. In addition, children of fathers who received the parenting intervention showed significantly greater improvements in social-emotional development scores (mean difference, −20.8; P < .001) at 6 months than children of those who received the treatment as usual. "We believe that this program could also be successful in other countries, including Canada," said Husain. "Canada is multicultural, and similar patterns of male postpartum depression probably exist here. We know that cultural and social pressures create barriers to seeking mental health support for men. Stigma and cultural beliefs often prevent new fathers from seeking the help they need. Programs like LTP + Dads can help men transition to their new role as fathers by giving them support to process their emotions," he said. Husain added that the program will be expanded throughout Pakistan to include about 4000 fathers and their partners. 'Remarkable' Success Rate "Postpartum depression in men is still something that people are trying to understand," John Ogrodniczuk, MD, professor of psychiatry and director of the psychotherapy program at The University of British Columbia in Vancouver, British Columbia, Canada, told Medscape Medical News. He did not participate in the study. "Understandably, most of the literature is around postpartum depression in women, not so much around men. The positive results seen here are interesting, especially in a country that is patriarchal and where there is not a lot of uptake of mental health interventions and services by men," he said. "The success rate of this psychosocial intervention is remarkable, so I am excited to see that the researchers have secured funding to expand the study and validate their results with a larger group of participants," Simon B. Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told Medscape Medical News . "I am also encouraged by the inclusion of play-based activities in addition to cognitive behavioral therapy. Perhaps more than any other role we hold through life, the role of parent comes with copious societal and personal expectations, plus with all that pressure, transitioning into that role is hard for everyone, but especially for those with postpartum depression. Supporting parents and improving their mental well-being goes a long way toward raising mentally healthy kids," said Sherry, who was not part of the study. The study was funded by a grant from Grand Challenges Canada, an Academic Scholars Award from the Department of Psychiatry at the University of Toronto, and a Tier 2 Canada Research Chair from the Canadian Institutes of Health Research. Husain reported receiving grants from COMPASS Pathfinder, stock options from Mindset Pharma, and personal fees from Wake Network, outside the submitted work. He previously served as a trustee for the Pakistan Institute of Living and Learning. Ogrodniczuk and Sherry reported no relevant financial relationships. Note: This article originally appeared on Medscape .