Depression is one of the most common mental health disorders globally, affecting millions of people each year. While traditional therapies like antidepressants and psychotherapy have benefited many people, a large number of patients continue to suffer from symptoms despite trying various therapies. This illness is commonly referred to as treatment resistant depression. Ketamine therapy has recently emerged as a game changing potential in mental health treatment. Developed initially as an anesthetic, ketamine is currently used in supervised medical settings to treat severe depression, suicidal thoughts, anxiety, and post-traumatic stress disorder (PTSD). What distinguishes ketamine therapy is its capacity to deliver immediate symptom alleviation compared to other antidepressants, which can take weeks or even months to provide results. As science advances, ketamine therapy is altering how mental health practitioners approach depression treatment and providing hope to individuals who previously believed they had exhausted all alternatives. What is Ketamine Therapy? For decades, hospitals have safely utilized ketamine as an anesthetic for procedures and medical treatments. Over time, researchers discovered that low doses of ketamine could have strong antidepressant effects. Ketamine therapy for depression is commonly provided in a variety of ways, including: Intravenous (IV) Infusions Nasal spray treatments Intramuscular injections. Oral lozenges or pills, in some situations. Ketamine, unlike other antidepressants, affects the brain's glutamate system. This unique mechanism is one reason why ketamine may benefit people who do not react to conventional treatments. How Ketamine works in the brain Researchers believe that ketamine works by targeting glutamate, the brain's most abundant neurotransmitter. Glutamate plays an important role in learning, memory, and brain transmission. Ketamine appears to help the brain form new neural connections, a process known as neuroplasticity. Depression can interfere with normal communication between brain cells, but ketamine may help repair and strengthen these pathways. This increased connectivity could explain why some patients report reduction from depressed symptoms within hours or days of treatment. Ketamine treatment could help reduce: Persistent sadness. emotional numbness. Hopelessness. Suicidal ideas. Anxiety Symptoms. Lack of motivation. Although researchers continue to examine the specific mechanisms, current studies suggest that ketamine has the potential to quickly reset certain brain functions affected by depression. Is Ketamine Treatment Safe? Ketamine therapy, when offered by skilled medical professionals, is generally considered as safe for qualified candidates. Ketamine therapy, like any other medical treatment, can carry risks and side effects. Common brief side effects may include: Dizziness. Nausea. High blood pressure. Blurred vision. Mild dissociation. Fatigue. These effects normally subside quickly after the session ends. Ketamine therapy is not appropriate for everyone. Individuals with particular medical concerns, such as uncontrolled hypertension, active substance misuse, or mental illnesses, may require further evaluation or other treatment options. This is why professional assessment and continued monitoring are critical components of safe ketamine therapy treatment plans. Conclusion Ketamine therapy is revolutionizing depression treatment by providing a quicker and possibly more effective option for people suffering from severe or treatment-resistant depression. Its different impacts on the brain, fast symptom relief, and potential to promote neuroplasticity have opened up new possibilities in mental health treatment. For many patients who had previously felt attached by chronic depression, ketamine therapy provided new hope and a significant improvement in quality of life. As science advances and mental health care evolves, ketamine therapy may play an increasingly essential role in overall depression treatment plans. When given responsibly under medical supervision, it represents an important step forward in addressing one of the world's most difficult mental health conditions.

According to Jordan Peterson, recovering from emotional trauma begins with confronting the truth about your experience rather than avoiding it. Suppressed pain does not go away, it resurfaces as worry, despair, or harmful tendencies. He emphasizes the significance of clearly expressing your suffering, whether through writing or honest speech, as this helps arrange jumbled feelings into something bearable. Accepting responsibility for your life, even in tiny ways, is essential to healing. Peterson also emphasizes the importance of courage in confronting traumatic memories gradually rather than being overwhelmed by them. Building supportive relationships and obtaining expert help might hasten healing. Finally, he defines recovery as a process of integrating the past rather than eliminating it, allowing people to move forward with greater resilience, purpose, and a deeper sense of self. Great video about dealing from emotional trauma

How neuroinflammation is misdiagnosed and mistreated by clinicians. Key points Kids with inflamed brains are misdiagnosed with behavior problems instead of neuroimmune conditions. Standard intakes miss infections, flares, and neuroimmune red flags that precede “sudden” psychiatric decline. Before labeling kids, we must rule out neuroinflammation and treat the immune system, not just the behavior. Our children are sitting in therapy offices with inflamed brains. Psychiatrists are prescribing medications for immune-driven symptoms. Parents are being counseled on behavior while their child’s immune system attacks the brain. This is not rare. This is systematic. The mental health system is structurally designed to miss neuroimmune disease, not because clinicians are incompetent, but because the diagnostic framework itself cannot see what it was never built to recognize. Every intake form, every assessment protocol, every treatment algorithm moves a child with brain inflammation directly into psychiatric care without ever asking if the brain itself is diseased. For example, a mother brings her 12-year-old daughter for a psychiatric evaluation. The intake focuses on family stressors, school functioning, trauma history, mood patterns, and behavioral challenges. What the therapist does not ask is equally important. No one asks whether she was recently sick. No one asks about tick exposure, sudden cognitive slowing, episodes where she seems disconnected, or rages that look panicked rather than oppositional. No one asks whether symptoms shift dramatically from one day to the next in ways that do not fit any psychological pattern. Or if there are significant fluctuating changes after she gets sick. This is not due to incompetence. The standard intake form does not include these questions. The diagnostic model does not recognize these clues. The child has a neuroimmune disorder. The intake will not uncover it. Psychiatric treatment starts. Her condition worsens. And because no one is trained to consider brain inflammation, no one identifies the true cause. How the System Misses Neuroimmune Root Causes The mental health system is structurally incapable of recognizing neuroimmune disease. Psychiatrists are trained in psychopharmacology, not immunology. Therapists are trained to observe symptoms from a psychological perspective, not infectious disease. We operate in separate domains. A child with brain inflammation falls through the gaps. Our diagnostic categories describe phenomenology, not causation (Insel, 2013). "Major depressive disorder" tells us about symptoms, nothing about whether those symptoms originate from monoamine deficiency, hypothyroidism, or brain inflammation. We treat the category without investigating the mechanism. Before psychiatric diagnosis, we should rule out five critical neurological root causes (Gertel Kraybill, 2020): underlying infections (including PANS/PANDAS and autoimmune encephalitis) traumatic brain injury medication side effects genetic predisposition environmental factors Yet insurance reimburses therapy and medication management but resists comprehensive medical workups for "behavioral" symptoms (Swedo et al., 2012). The system incentivizes psychiatric treatment rather than medical investigation. What Neuroimmune Reactive Avoidance Reveals Neuroimmune Reactive Avoidance (NRA) is a framework I developed to understand how immune dysregulation produces specific behavioral manifestations often misidentified as psychiatric resistance (Gertel Kraybill, 2025). The avoidance is not psychological; it is a direct neurological consequence of neuroinflammation. Read more about NRA here. When the brain is inflamed, it cannot properly execute motor planning and behavioral initiation. When the prefrontal cortex is compromised by immune attack, it cannot regulate impulse and emotion (Dalmau & Graus, 2018). The child experiences demand as neurologically intolerable because the neural circuits required to respond are actively compromised. This is why cognitive-behavioral interventions fail. We attempt to modify behavior by engaging cognitive processes in a brain that cannot execute those processes. The inflammation must be addressed first. Distinguishing Clinical Features Parents describe children as "not there," having vacant eyes, and confused by their own behavior. This is altered consciousness and loss of volitional control, not anxiety or opposition. Symptoms fluctuate with immune activity. A child is functional for three days, incapacitated for two, and then functional again. This correlates with immune flares (Chang et al., 2015; Gertel Kraybill, 2025). Psychiatric conditions don't fluctuate in this way. The symptom constellation crosses domains: avoidance plus motor tics plus urinary urgency plus handwriting deterioration plus sleep fragmentation plus sudden food restrictions (Gertel Kraybill, 2020). These reflect inflammatory processes affecting multiple brain regions. Most significant is the response to immunological treatment versus psychiatric treatment. When immune dysregulation is addressed, symptoms can improve dramatically (Frankovich et al., 2015). With only psychiatric medications, improvement is minimal or absent. The Moment a Child Is Saved or Lost A 10-year-old develops strict avoidant/restrictive food intake disorder (ARFID) and almost stops eating, repeating, "I want to die." Door 1: Intake. Depression diagnosis. SSRI prescribed. Activation syndrome. Switch medications. Antipsychotic added. Day 120: Three medications, out of school for four months, parents devastated, marriage fracturing. The child has autoimmune encephalitis. Every day without treatment, inflammation continues. The condition becomes more chronic and resistant to any intervention. Door 2: Day 1: Clinician recognizes acute presentation, asks about recent illness, and refers to a neurologist. Day 7: Elevated inflammatory markers, positive autoantibodies, recent strep. Day 8: Treatment begins. Day 14: Significant improvement, child is eating, and suicidal ideation has resolved. Day 30: Continued improvement with accommodations. The difference is medical treatment of disease versus years of psychiatric intervention for symptoms caused by untreated inflammation. The difference is medical treatment of disease versus years of psychiatric intervention for symptoms caused by untreated inflammation. The Mother Who Knew Her son got the flu. Two weeks later, everything collapsed. He could not tolerate anyone speaking, developed tics, washed his hands compulsively, and screamed about things touching him when nothing was there. The pediatrician said it was anxiety. The therapist said it was OCD. The psychiatrist said they should start an SSRI. She kept repeating that it all began after he was sick and that something was wrong with his brain. They kept insisting that children can develop anxiety suddenly and that he needed therapy and medication. She documented every symptom. She found information about PANDAS, brought articles to appointments, and was dismissed. She was told it was controversial and that her son simply had anxiety. Eventually, she found a PANS-informed doctor four hours away and paid out of pocket. Testing showed elevated strep antibodies. Treatment began. Her son improved. She spent six months fighting every professional. Her son's pediatrician and two others told her she was wrong. But what happens to parents who trust the system? What happens to families without resources? Those children fall apart while everyone believes they are doing the right thing. I Am That Mother My story is different yet grounded in the same core reality. I was dismissed repeatedly by medical providers even though I, as the parent, held the only complete perspective on my child’s symptoms and their timeline. This should never hinge on whether I am a therapist or a stay-at-home parent. Clinicians must recognize parents as the primary source of information, the ones who witness the onset, the pattern, and the suffering, and who hold the deepest authority on their child’s well-being. What Must Change Medical screening before psychiatric diagnosis. For any child with acute-onset neuropsychiatric symptoms, medical rule-outs should be mandatory: inflammatory markers, autoimmune screening, and infection testing. If red flags exist, there should be an immediate neurology referral. Integrated training. Every mental health professional should recognize presentations warranting neuroimmune investigation and know when to refer. Interdisciplinary care. We need clinics where psychiatrists work alongside neurologists and immunologists. These are extremely rare. For Parents and Clinicians Parents: You know something is medically wrong. Your knowing is dismissed as denial. You watch treatment fail while being counseled on consistency. Trust your observations. Document everything. Find clinicians who investigate rather than dismiss. Do not accept a diagnosis until neuroimmune root causes are ruled out. Clinicians: We are failing these children and their families. Learn to recognize these presentations. Develop relationships with neuroimmune specialists. Refer early. Listen when parents insist that something is medically wrong. This Reality Is Unacceptable When a child presents with NRA, we are looking at brain inflammation producing neurological symptoms that manifest behaviorally. Until our diagnostic frameworks, training, insurance systems, and clinical practice align around this reality, children and their families will continue to suffer from well-intentioned treatment of the wrong thing. We know how to identify these conditions. We know how to treat them. We are simply not doing it. This should enrage us. That anger belongs in the service of real systemic change for children who are suffering. As a PANDAS and autoimmune encephalitis mother, I am heartbroken by the consequences of uninformed medical care and by professionals who are not willing to listen or to treat my son appropriately. Week after week, new data show how strongly the immune system shapes neuropsychiatric symptoms. It is no longer acceptable to ignore this science. We must all get informed. Note: This article originally appeared on Psychology Today.

"The history of psychiatry is a history of fads in theory, diagnosis, and treatment. Such rapid shifts in conceptualization such as the emergence of the concept of adult ADHD almost always warrant informed critical examination." COMMENTARY As recently as 2 decades ago, the consensus view in American academic psychiatry was that attention-deficit/hyperactivity disorder (ADHD) rarely, if ever, persists into adulthood.1,2 For decades, ADHD was considered a disorder of childhood, adult cases were seen uncommonly and the diagnosis was rarely made. DSM-IV-TR, published in 2000, describes a condition existing in children and makes only scant reference to adults. Fast-forward to 2023, and adult ADHD is the diagnosis du jour; rates of diagnosis are skyrocketing at an alarming rate as are prescriptions for psychostimulants, the drugs that purportedly treat the condition. The history of psychiatry is a history of fads in theory, diagnosis, and treatment. Such rapid shifts in conceptualization—such as the emergence of the concept of adult ADHD—almost always warrant informed critical examination. In the case of a novel psychiatric disorder, it is either true that (1) psychopathologists and psychiatric nosologists have missed the disorder for more than a century, or (2) that the disorder is a case of disease mongering, when a condition that has never been observed is suddenly made popular overnight as a result of social, cultural, and economic reasons. We argue that the latter is true for adult ADHD. How did adult ADHD get its wheels? The rise in diagnosis of adult ADHD fully coincides with marketing by the pharmaceutical industry when Eli Lilly and Company got the first US Food and Drug Administration indication for this label with atomoxetine (Strattera) in 1996. Since that date, many academics have been promoting the concept of adult ADHD. The adult ADHD market has become a multibillion-dollar industry, with the rise of digital companies specializing in online diagnosis and treatment—some of which have come under legal scrutiny. Does ADHD Persist Into Adulthood? Findings from commonly cited retrospective studies suggest that approximately 50% to 60% of childhood ADHD persists into adulthood. These studies look backwards to attempt to determine which childhood cases continue into adulthood. However, these data are disproven by prospective studies, which repeatedly show that about 80% of children with ADHD do not continue to have that diagnosable condition, followed prospectively either into young adulthood or even for 33 years into their fourth decade of life (Figure). A total of 20% of cases persist, whereas 80% do not. In other words, most children with ADHD do not continue to meet the criteria for the diagnosis into adulthood. Construct Validity and Diagnostic Hierarchy When we argue that adult ADHD is not a scientifically valid diagnosis, we do not mean, of course, that the symptoms so attributed do not exist. Clearly, adult human beings can exhibit problems with attention, concentration, focus, memory, and related abilities. What we mean is that these symptoms have not been shown to be the result of a scientifically valid disease (adult ADHD) and are better explained by more classic and scientifically validated psychiatric conditions, namely diseases or abnormalities of mood, anxiety, and mood temperament. A major problem with the DSM system as currently constituted is that it fails to take into account the concept of diagnostic hierarchy, a fundamental diagnostic principle used across medicine. In sum, diagnostic hierarchy refers to the idea that not all diagnoses are created equal that some are more important or more primary than others. Failure to adhere to the concept of diagnostic hierarchy has resulted in epidemics of polydiagnosis (assigning multiple diagnoses to the same patient) and polypharmacy (the use of multiple psychiatric medications, often across classes). What Causes the Symptoms Attributed to Adult ADHD? Plenty of other psychiatric disorders exist that can cause ADHD-like symptoms, and in current practice, individuals with these symptoms receive misdiagnoses of adult ADHD. For example, 84% of patients with symptoms meeting criteria for adult ADHD also have symptoms that meet criteria for mood illnesses.6 Using the concept of diagnostic hierarchy, poor attention is a symptom of depression, mania, and anxiety; thus, the occurrence of inattention while a patient has mood symptoms does not mean the patient has both an attention disorder and a mood disorder. This would be like saying every person with pneumonia also has a fever disorder. It is common to find that someone who thinks they have adult ADHD has another illness, such as a mood or anxiety condition, that causes the symptom of inattention. Another underappreciated consideration is the concept of mood temperament. Unlike the symptoms of major mood disorders, mood temperaments do not come and go; they are present all the time as part of one’s personality. Conditions such as cyclothymia, hyperthymia, and dysthymia involve constant presence of mild manic and/or depressive symptoms. Since these manic and/or depressive symptoms are present all the time, they can produce inattention, poor concentration, and poor executive function all the time. One of us (NG) recently published with colleagues the first study on the topic of misdiagnosis of mood temperament on ADHD.7 We found that 62% of patients who received a diagnosis of adult ADHD actually have an affective temperament, most commonly cyclothymia (42%). In patients treated with amphetamine, mood symptoms predictably worsened. Why Do the Drugs Work? A common claim is that since psychostimulants improve the cognition of individuals diagnosed with adult ADHD, then they must be treating an underlying disorder. But this is faulty logic. Psychostimulants improve cognition for everyone, including normal patients without psychiatric illness. It is because they have this general effect that they are so widely abused; it says nothing about the existence of adult ADHD. Concluding Thoughts The history of psychiatry teaches us that the field has been vulnerable to a host of diagnostic fads. Adult ADHD is the latest of such fads, and a careful review of the scientific literature reveals that the range of ADHD-like symptoms in adults is more accurately explained by other empirically validated psychiatric disorders. This has significant ramifications for therapy, given the wide use of psychostimulants in the treatment of these patients. The opinions expressed are those of the authors and do not necessarily reflect the opinions of Psychiatric Times. Dr Ruffalo is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. Dr Ghaemi is director of the Psychopharmacology Consultation Clinic at Tufts Medical Center and a professor of psychiatry at Tufts University School of Medicine. Related Articles Attention Deficit Hyperactivity Disorder (ADHD) Paying Attention to ADHD Prescriptions in Your Community Amid Shortages, Federal Agencies Ask Drugmakers to Boost Output of ADHD Meds ADHD Underappreciated in Older Adults

Key Takeaways Immersive VR meditation offers personalized experiences, enhancing symptom relief for MDD and GAD compared to traditional meditation. The study utilized Meta Oculus Quest 2 headsets, with participants engaging in 30-minute sessions over 10 weeks. Emotional regulation improvements were measured using HeartMath biofeedback, affirming VR meditation's efficacy. Limitations include a single-arm design and small sample size, yet findings support VR integration in mental health care. A new study shows that meditation using immersive virtual reality devices provides greater relief from major depressive disorder (MDD) and generalized anxiety disorder (GAD) symptoms than meditation alone. “Treatments that use medications are the most effective in addressing mental health disorders, but they also can bring unwanted side effects,” said Junhyoung Kim, PhD, a researcher in the Department of Health Behavior involved with the study. “That led to the current effort to develop treatments that rely less on drugs or are entirely drug-free, such as the practice of mindfulness through meditation.” In this longitudinally designed, single-arm clinical trial, participants used Meta brand Oculus Quest 2 digital headsets for 30-minute meditation sessions 3 times a week for 10 weeks. Investigators recruited participants based on referrals from clinician progress notes and initial entrance exams. Of the initial group of 36 participants, each participant engaged in an average of 5.1 sessions, but 11 participants left the study without undergoing the exit assessment when they were discharged from the hospital. This left the 25 participants—11 males and 14 females, with a mean age of 42.1 years—who took part in an average of 2.7 intervention sessions, equaling a total of 68 observations. The most important part of immersive virtual reality meditation that distinguishes it from traditional meditation is the personalized meditation experience. The headsets provided an immersive virtual reality experience in which users selected their desired outcome, such as stress reduction or improved sleep3,4; scenery, like a meadow, savannah, or beach; and natural sounds, like birds chirping. The 30-minute sessions were provided according to the preference and requirements of each participant. Before and after each session, participants completed a General Anxiety Disorder-7 questionnaire. They also completed the Patient Health Questionnaire-9 before and after 2 sessions. Investigators also used HeartMath (electrocardiogram) to measure the changes in emotional regulation related to immersive virtual reality meditation participation. HeartMath, a biofeedback monitoring system that measures heart rhythm changes and coherence levels between sympathetic and parasympathetic activities in the autonomic nervous system,5 allowed investigators to objectively measure coherence level and related achievement scores that are associated with levels of depression and anxiety (Drageset et al., 2012; Edwards, 2016; Minen et al., 2021). The study affirmed previous findings that virtual reality meditation sessions significantly alleviated participants’ MDD and GAD symptoms and improved their emotional regulation. “This is important knowledge for mental health professionals, clinicians and caregivers,” Kim said. “Meditation using immersive virtual reality has the potential to greatly benefit those in the United States who will experience depression at some point.” Limitations included the single arm clinical trial and small sample size. “While the outcomes of the study cannot be generalized and there are reliability issues, our study can serve as an initial test of the application of a technology to mindfulness therapy for MDD and GAD patients,” wrote the study authors. “The results of our study provide a rationale for implementing immersive virtual reality meditation with patients with MDD and GAD and shed light on how mental health professionals, clinical practitioners, and caregivers can integrate VR technology into existing mental health care programs.” Note: This article originally appeared on Psychiatric Times.

Bipolar disorder is a brain disorder that causes changes in a person's mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes. These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or depressive (sad mood). People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives. People without bipolar disorder experience mood fluctuations as well. However, these mood changes typically last hours rather than days. Also, these changes are not usually accompanied by the extreme degree of behavior change or difficulty with daily routines and social interactions that people with bipolar disorder demonstrate during mood episodes. Bipolar disorder can disrupt a person’s relationships with loved ones and cause difficulty in working or going to school. Bipolar disorder is a category that includes three different diagnoses: Bipolar I, Bipolar II, and Cyclothymic disorder. Risk Factors: Bipolar disorder commonly runs in families: 80 to 90 percent of individuals with bipolar disorder have a relative with bipolar disorder or depression. Environmental factors such as stress, sleep disruption, and drugs and alcohol may trigger mood episodes in vulnerable people. Though the specific causes of bipolar disorder within the brain are unclear, an imbalance of brain chemicals is believed to lead to dys-regulated brain activity. The average age of onset is 25 years old. People with bipolar I disorder frequently have other mental disorders such as anxiety disorders, substance use disorders, and/or attention-deficit/hyperactivity disorder (ADHD). The risk of suicide is significantly higher among people with bipolar I disorder than among the general population. Bipolar I Disorder Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic episode, people with bipolar I disorder experience an extreme increase in energy and may feel on top of the world or uncomfortably irritable in mood. Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most people with bipolar I disorder also have periods of neutral mood. Symptoms of Bipolar I Disorder Manic Episode A manic episode is a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior: Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual Increased or faster speech Uncontrollable racing thoughts or quickly changing ideas or topics when speaking Distractibility Increased activity (e.g., restlessness, working on several projects at once) Increased risky behavior (e.g., reckless driving, spending sprees These behaviors must represent a change from the person’s usual behavior and be clear to friends and family. Symptoms must be severe enough to cause dysfunction in work, family, or social activities and responsibilities. Symptoms of a manic episode commonly require a person to receive hospital care to stay safe. Some people experiencing manic episodes also experience disorganized thinking, false beliefs, and/or hallucinations, known as psychotic features. Hypomanic Episode A hypomanic episode is characterized by less severe manic symptoms that need to last only four days in a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause. Major Depressive Episode A major depressive episode is a period of at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms): Intense sadness or despair Loss of interest in activities the person once enjoyed Feelings of worthlessness or guilt Fatigue Increased or decreased sleep Increased or decreased appetite Restlessness (e.g., pacing) or slowed speech or movement Difficulty concentrating Frequent thoughts of death or suicide Treatment and Management Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn about their illness and adhere to medications, preventing future mood episodes. Medications known as “mood stabilizers” (e.g., lithium) are the most commonly prescribed type of medications for bipolar disorder. These medications are believed to correct imbalanced brain signaling. Because bipolar disorder is a chronic illness in which mood episodes typically recur, ongoing preventive treatment is recommended. Bipolar disorder treatment is individualized. People with bipolar disorder may need to try different medications before finding what works best for them. In some cases, when medication and psychotherapy have not helped, an effective treatment known as electroconvulsive therapy (ECT) may be used. However, there can be short-term or long-term effects on memory, therefore it should be used as a last resort as based on the severity of symptoms. It is typically recommended to have 10-12 sessions spread out over 3 weeks, otherwise there is increase risk of memory impairment. ECT involves several rounds of a brief electrical current applied to the scalp while the patient is under anesthesia, leading to a short, controlled seizure. ECT-induced seizures are believed to remodel brain signaling pathways. Since bipolar disorder can cause serious disruptions in a person’s daily life and create a stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies for coping, participating actively in the treatment, and obtaining support. Bipolar II Disorder A diagnosis of bipolar II disorder requires someone to have at least one major depressive episode and at least one hypomanic episode (see above). People return to their usual functioning between episodes. People with bipolar II disorder often first seek treatment as a result of their first depressive episode, since hypomanic episodes often feel pleasurable and can even increase performance at work or school. People with bipolar II disorder frequently have other mental illnesses such as an anxiety disorder or substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania. Treatment Treatments for bipolar II are similar to those for bipolar I: medication and psychotherapy. The most commonly used medications are mood stabilizers and antidepressants, depending on the specific symptoms. If depressive symptoms are severe and medication is not effective, ECT (see above) may be used. Each person's treatment is individualized. Cyclothymic Disorder Cyclothymic disorder is a milder form of bipolar disorder involving many "mood swings," with hypomania and depressive symptoms that occur frequently. People with cyclothymia experience emotional ups and downs but with less severe symptoms than bipolar I or II disorder. Cyclothymic disorder symptoms include the following: For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do not meet the criteria for hypomanic or depressive episode. During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months. Treatment Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of mood swings. Keeping a mood journal can be an effective way to observe patterns in mood fluctuation. People with cyclothymia may start and stop treatment over time.

Neurodiversity is often in the headlines, with articles ranging from scaremongering about an explosion in diagnoses to helpful and informative pieces on how best to support neurodivergent family, friends, and colleagues. The amount of information available can feel overwhelming and confusing, given the proliferation of opinion on the issue. As a neurodivergent individual myself, navigating this range of content can be challenging and frustrating. One moment it feels supportive and validating; the next it can feel quite the opposite. To mark Neurodiversity Celebration Week 2026, I’m looking at what neurodiversity is and what is happening across the healthcare profession to support neurodivergent colleagues Understanding Neurodiversity Starting with the basics, neurodiversity simply refers to the natural diversity of human brains and how they function. Neurodivergent individuals are those whose brains and cognitive functioning differ from what is considered typical. It is estimated that we make up to 15% of the population. Neurodivergent conditions include autism, ADHD, dyslexia, dyspraxia, dyscalculia, and Tourette syndrome. Although diagnoses of many neurodivergent conditions are increasing, this may not reflect increasing prevalence. Instead, it may result from greater awareness, wider diagnostic criteria, and improved understanding of these conditions — particularly in adults and women. Understanding the variance in neurodivergent conditions can help clinicians better understand their patients and improve relationships with colleagues. The proportion of healthcare professionals who may be neurodivergent is difficult to assess. Many remain undiagnosed, while others may hide or mask their diagnosis or differences. A 2025 study of doctors accessing NHS Practitioner Health for mental health support found that 35% screened positive for ADHD, which is significantly higher than the 2%-3% prevalence in the general population. Small studies in Saudi Arabia and China have also reported higher rates of ADHD in medical students compared with the general population. It is possible that healthcare careers attract neurodivergent individuals because of the strengths that can accompany their conditions. However, it is important not to gloss over the potential challenges that may sit alongside them. For example, clinicians with autism may have excellent attention to detail, strong memory, innovative approaches to problem-solving, exceptional visual and mathematical abilities, and strong adherence to guidance. They may also demonstrate honesty, punctuality, and reliability. But the flip side to this is that they may face challenges managing uncertainty, struggle with social rules, find sensory environments overstimulating, and be at higher risk for burnout due to masking to fit into social norms. Individuals with ADHD may benefit from hyperfocus, respond well in high-pressure situations, and bring high energy, cognitive flexibility, and creativity. They may thrive when multitasking and problem-solving. Conversely, they may struggle with sustained focus, impulsivity, time management, hyperactivity, and sensitivity to perceived criticism. Supporting an Inclusive Workplace A risk in the current dialogue is that neurodivergent individuals become labelled or placed in diagnostic boxes that fail to reflect them as individuals. This can inadvertently reinforce stigma associated with neurodivergent diagnoses. As a result, clinicians could feel compelled to hide their diagnoses, mask symptoms, or avoid seeking appropriate support. There is also a huge amount of misinformation about neurodivergence, especially on social media. While much of this content may be well intentioned aiming to raise awareness and encourage inclusivity it can contribute to misunderstandings about what neurodivergence is, how it may manifest in individuals, and what support people might need. This can have a huge impact on individual clinicians and the support they receive. In turn, this may increase the risk of additional challenges, including mental health difficulties, which can affect both colleagues and patient safety. At the Medical Protection Society, when assisting members, we always take a holistic approach to ensure that all factors that may have contributed to incidents or allegations are considered. These can include health issues, resourcing pressures, systemic problems, or other personal circumstances. Encouragingly, we are seeing signs that other organisations and stakeholders involved in many of our cases are taking a similar approach, including a greater acknowledgement and understanding of neurodivergent conditions and the impacts they may have on the individual and their practice. Recently, NHS Resolution’s Practitioner Performance Advice Service published guidance to assist employers in understanding when neurodivergence may underlie performance concerns, how to provide support, and ensure that any concerns are addressed fairly, proportionately, and consistently. Similarly, many Royal Colleges have produced guidance on supporting neurodivergent clinicians and leveraging their strengths, which may benefit both neurodivergent and neurotypical staff. The General Medical Council also recognises in its guidance that a diverse population is better served by a diverse workforce that has had similar experiences and understands their needs. The Medical Practitioners Tribunal Service guidance also acknowledges that neurodivergence can influence cognition, communication, and perception of behaviour. These positive steps help to ensure that neurodivergence can be considered as part of a valid explanation for behaviours, by providing context and understanding, while refraining from using it as an excuse or exemption from accountability. One of the great strengths of medicine is the diversity it encompasses. Alongside this comes space for variation in individuals who can thrive in a medical career through different forms of knowledge, skill sets, personalities, and abilities. By embracing neurodivergence and developing a deeper understanding of what it encompasses, we may recognise it as another way to support and empower ourselves and our colleagues and ultimately provide better care for our patients. Note: This article originally appeared on Medscape.

What is ADHD and Adults Care with a Specialist Psychiatrist? Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. Symptoms of ADHD include inattention (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) and impulsivity (hasty acts that occur in the moment without thought). ADHD is considered a chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships, and daily functioning (Harpin, 2005). ADHD can lead to poor self-esteem and social function in children when not appropriately treated (Harpin et al., 2016). Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism possibly stemming from higher levels of criticism throughout life (Beaton, et al., 2022). Of note, ADHD presentation and assessment in adults differs. This page focuses on children. An estimated 8.4% of children and 2.5% of adults have ADHD (Danielson, 2018; Simon, et al., 2009). ADHD is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. It is more commonly diagnosed among boys than girls given differences in how the symptoms present. However, this does not mean that boys are more likely to have ADHD. Boys tend to present with hyperactivity and other externalizing symptoms whereas girls tend to have inactivity. Symptoms and Diagnosis Many children may have difficulties sitting still, waiting their turn, paying attention, being fidgety, and acting impulsively. However, children who meet diagnostic criteria for ADHD, differ in that their symptoms of hyperactivity, impulsivity, organization, and/or inattention are noticeably greater than expected for their age or developmental level. These symptoms lead to significant suffering and cause problems at home, at school or work, and in relationships. The observed symptoms are not the result of an individual being defiant or not being able to understand tasks or instructions. There are three main types of ADHD: Predominantly inattentive presentation. Predominantly hyperactive/impulsive presentation. Combined presentation. A diagnosis is based on the presence of persistent symptoms that have occurred over a period of time and are noticeable over the past six months. While ADHD can be diagnosed at any age, this disorder begins in childhood. When considering the diagnosis, the symptoms must be present before the individual is 12 years old and must have caused difficulties in more than one setting. For instance, the symptoms can not only occur at home. Inattentive type Inattentive refers to challenges with staying on task, focusing, and organization. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Doesn’t pay close attention to details or makes careless mistakes in school or job tasks. Has problems staying focused on tasks or activities, such as during lectures, conversations or long reading. Does not seem to listen when spoken to (i.e., seems to be elsewhere). Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties (may start tasks but quickly loses focus). Has problems organizing tasks and work (for instance, does not manage time well; has messy, disorganized work; misses deadlines). Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms. Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone and eyeglasses. Is easily distracted. Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills and keep appointments. Hyperactive/impulsive type Hyperactivity refers to excessive movement such as fidgeting, excessive energy, not sitting still, and being talkative. Impulsivity refers to decisions or actions taken without thinking through the consequences. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Fidgets with or taps hands or feet, or squirms in seat. Not able to stay seated (in classroom, workplace). Runs about or climbs where it is inappropriate. Unable to play or do leisure activities quietly. Always “on the go,” as if driven by a motor. Talks too much. Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations). Has difficulty waiting for his or her turn, such as while waiting in line. Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing. Combined type This type of ADHD is diagnosed when both criteria for both inattentive and hyperactive/impulse types are met. ADHD is typically diagnosed by mental health providers or primary care providers. A psychiatric evaluation will include a description of symptoms from the patient and caregivers, completion of scales and questionnaires by patient, caregivers and teachers, complete psychiatric and medical history, family history, and information regarding education, environment, and upbringing. It may also include a referral for medical evaluation to rule out other medical conditions. It is important to note that several conditions can mimic ADHD such as learning disorders, mood disorders, anxiety, substance use, head injuries, thyroid conditions, and use of some medications such as steroids (Austerman, 2015). ADHD may also co-exist with other mental health conditions, such as oppositional defiant disorder or conduct disorder, anxiety disorders, and learning disorders (Austerman, 2015). Thus, a full psychiatric evaluation is very important. There are no specific blood tests or routine imaging for ADHD diagnosis. Sometimes, patients may be referred for additional psychological testing (such as neuropsychological or psychoeducational testing) or may undergo computer-based tests to assess the severity of symptoms. The Causes of ADHD Scientists have not yet identified the specific causes of ADHD. While there is growing evidence that genetics contribute to ADHD and several genes have been linked to the disorder, no specific gene or gene combination has been identified as the cause of the disorder. However, it is important to note that relatives of individuals with ADHD are often also affected. There is evidence of anatomical differences in the brains of children with ADHD in comparison to other children without the condition. For instance, children with ADHD have reduced grey and white brain matter volume and demonstrate different brain region activation during certain tasks (Pliszka, 2007). Further studies have indicated that the frontal lobes, caudate nucleus, and cerebellar vermis of the brain are affected in ADHD (Tripp & Wickens, 2009). Several non-genetic factors have also been linked to the disorder such as low birth weight, premature birth, exposure to toxins (alcohol, smoking, lead, etc.) during pregnancy, and extreme stress during pregnancy. ADHD Treatment ADHD treatment usually encompasses a combination of therapy and medication intervention. In preschool-age and younger children, the recommended first-line approach includes behavioral strategies in the form of parent management training and school intervention. Parent-Child Interaction Therapy (PCIT) is an evidence-based therapy modality to help young children with ADHD and oppositional defiant disorder. According to current guidelines, psychostimulants (amphetamines and methylphenidate) are first-line pharmacological treatments for the management of ADHD (Pliszka, 2007). In preschool-aged patients with ADHD, amphetamines are the only FDA-approved medication, although guidelines suggest that methylphenidate rather than amphetamines may be helpful if behavioral interventions prove insufficient. Alpha agonists (clonidine and guanfacine) and the selective norepinephrine reuptake inhibitor, atomoxetine, are the other FDA-approved options for treating ADHD. There are newer FDA-approved medications for ADHD treatment, including Jornay (methylphenidate extended-release) which is taken at night and starts the medication effect the next morning, Xelstrym (dextroamphetamine) which is an amphetamine patch, Qelbree (viloxazine) which is a non-stimulant, Adhansia (methylphenidate hydrochloride), Dyanavel (amphetamine extended-release oral suspension), Mydayis (mixed salts amphetamine product), and Cotempla (methylphenidate extended-release orally disintegrating tablets). Many children and families can alternate between various medication options depending on the efficacy of treatment and tolerability of the medication. The goal of treatment is to improve symptoms to restore functioning at home and at school. ADHD and School-Aged Children Teachers and school staff can provide parents and doctors with information to help evaluate behavior and learning problems and can assist with behavioral training. However, school staff cannot diagnose ADHD, make decisions about treatment or require that a student take medication to attend school. Only parents and guardians can make those decisions with the child’s health care clinician. Students whose ADHD impairs their learning may qualify for special education under the Individuals with Disabilities Education Act or for a Section 504 plan (for children who do not require special education) under the Rehabilitation Act of 1973. Children with ADHD can benefit from study skills instruction, changes to the classroom setup, alternative teaching techniques and a modified curriculum. Source: Comprehensive Guide for Advocating for 504 vs IDEA ADHD and Adults Many children diagnosed with ADHD will continue to meet criteria for the disorder later in life and may show impairments requiring ongoing treatment (Pliszka, 2007). However, sometimes a diagnosis of ADHD is missed during childhood. Many adults with ADHD do not realize they have the disorder. A comprehensive evaluation typically includes a review of past and current symptoms, a medical exam and history, and use of adult rating scales or checklists. Adults with ADHD are treated with medication, psychotherapy or a combination. Behavior management strategies, such as ways to minimize distractions and increase structure and organization, and support from immediate family members can also be helpful. ADHD is a protected disability under the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). This means that institutions receiving federal funding cannot discriminate against those with disabilities. Individuals whose symptoms of ADHD cause impairment in the work setting may qualify for reasonable work accommodations under ADA. Related Conditions Autism spectrum disorder Disruptive, impulse control and conduct disorders Social communication disorder Specific learning disorder Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 2013.

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. It can lead to a variety of emotional and physical problems and can decrease your ability to function at work and at home. If you or someone you know needs support now, call or text 988,or chat 988lifeline.org Depression symptoms can vary from mild to severe and can include: Feeling sad or having a depressed mood Loss of interest or pleasure in activities once enjoyed Changes in appetite — weight loss or gain unrelated to dieting Trouble sleeping or sleeping too much Loss of energy or increased fatigue Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others) Feeling worthless or guilty Difficulty thinking, concentrating or making decisions Thoughts of death or suicide Symptoms must last at least two weeks and must represent a change in your previous level of functioning for a diagnosis of depression. Also, medical conditions (e.g., thyroid problems, a brain tumor or vitamin deficiency) can mimic symptoms of depression so it is important to rule out general medical causes. Depression affects an estimated one in 15 adults (6.7%) in any given year. And one in six people (16.6%) will experience depression at some time in their life. Depression can occur at any time, but on average, first appears during the late teens to mid-20s. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a major depressive episode in their lifetime. There is a high degree of heritability (approximately 40%) when first-degree relatives (parents/children/siblings) have depression. Depression Is Different From Sadness or Grief/Bereavement The death of a loved one, loss of a job or the ending of a relationship are difficult experiences for a person to endure. It is normal for feelings of sadness or grief to develop in response to such situations. Those experiencing loss often might describe themselves as being “depressed.” But being sad is not the same as having depression. The grieving process is natural and unique to each individual and shares some of the same features of depression. Both grief and depression may involve intense sadness and withdrawal from usual activities. They are also different in important ways: In grief, painful feelings come in waves, often intermixed with positive memories of the deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two weeks. In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and self-loathing are common. In grief, thoughts of death may surface when thinking of or fantasizing about “joining” the deceased loved one. In major depression, thoughts are focused on ending one’s life due to feeling worthless or undeserving of living or being unable to cope with the pain of depression. Grief and depression can co-exist. For some people, the death of a loved one, losing a job or being a victim of a physical assault or a major disaster can lead to depression. When grief and depression co-occur, the grief is more severe and lasts longer than grief without depression. Distinguishing between grief and depression is important and can assist people in getting the help, support or treatment they need. Risk Factors for Depression Depression can affect anyone even a person who appears to live in relatively ideal circumstances. Several factors can play a role in depression: Biochemistry: Differences in certain chemicals in the brain may contribute to symptoms of depression. Genetics: Depression can run in families. For example, if one identical twin has depression, the other has a 70 percent chance of having the illness sometime in life. Personality: People with low self-esteem, who are easily overwhelmed by stress, or who are generally pessimistic appear to be more likely to experience depression. Environmental factors: Continuous exposure to violence, neglect, abuse or poverty may make some people more vulnerable to depression. How Is Depression Treated? Depression is among the most treatable of mental disorders. Between 80% and 90% percent of people with depression eventually respond well to treatment. Almost all patients gain some relief from their symptoms. Before a diagnosis or treatment, a health professional should conduct a thorough diagnostic evaluation, including an interview and a physical examination. In some cases, a blood test might be done to make sure the depression is not due to a medical condition like a thyroid problem or a vitamin deficiency (reversing the medical cause would alleviate the depression-like symptoms). The evaluation will identify specific symptoms and explore medical and family histories as well as cultural and environmental factors with the goal of arriving at a diagnosis and planning a course of action. Medication Brain chemistry may contribute to an individual’s depression and may factor into their treatment. For this reason, antidepressants might be prescribed to help modify one’s brain chemistry. These medications are not sedatives, “uppers” or tranquilizers. They are not habit-forming. Generally antidepressant medications have no stimulating effect on people not experiencing depression. Antidepressants may produce some improvement within the first week or two of use yet full benefits may not be seen for two to three months. If a patient feels little or no improvement after several weeks, his or her psychiatrist can alter the dose of the medication or add or substitute another antidepressant. In some situations other psychotropic medications may be helpful. It is important to let your doctor know if a medication does not work or if you experience side effects. Psychiatrists usually recommend that patients continue to take medication for six or more months after the symptoms have improved. Longer-term maintenance treatment may be suggested to decrease the risk of future episodes for certain people at high risk. Psychotherapy Psychotherapy, or “talk therapy,” is sometimes used alone for treatment of mild depression; for moderate to severe depression, psychotherapy is often used along with antidepressant medications. Cognitive behavioral therapy (CBT) has been found to be effective in treating depression. CBT is a form of therapy focused on the problem solving in the present. CBT helps a person to recognize distorted/negative thinking with the goal of changing thoughts and behaviors to respond to challenges in a more positive manner. Psychotherapy may involve only the individual, but it can include others. For example, family or couples therapy can help address issues within these close relationships. Group therapy brings people with similar illnesses together in a supportive environment, and can assist the participant to learn how others cope in similar situations. Depending on the severity of the depression, treatment can take a few weeks or much longer. In many cases, significant improvement can be made in 10 to 15 sessions. Electroconvulsive Therapy (ECT) ECT is a medical treatment that has been most commonly reserved for patients with severe major depression who have not responded to other treatments. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient typically receives ECT two to three times a week for a total of six to 12 treatments. It is usually managed by a team of trained medical professionals including a psychiatrist, an anesthesiologist and a nurse or physician assistant. ECT has been used since the 1940s, and many years of research have led to major improvements and the recognition of its effectiveness as a mainstream rather than a "last resort" treatment. Short and long term use can lead to permanent memory issues. Self-help and Coping There are a number of things people can do to help reduce the symptoms of depression. For many people, regular exercise helps create positive feeling and improves mood. Getting enough quality sleep on a regular basis, eating a healthy diet and avoiding alcohol (a depressant) can also help reduce symptoms of depression. Depression is a real illness and help is available. With proper diagnosis and treatment, the vast majority of people with depression will overcome it. If you are experiencing symptoms of depression, a first step is to see your family physician or psychiatrist. Talk about your concerns and request a thorough evaluation. This is a start to addressing your mental health needs. Support Groups: Depression and Bipolar Support Alliance National Alliance on Mental Illness Related Conditions Peripartum depression (previously postpartum depression) Seasonal depression (Also called seasonal affective disorder) Bipolar disorders Persistent depressive disorder (previously dysthymia) (description below) Premenstrual dysphoric disorder (description below) Disruptive mood dysregulation disorder (description below) Premenstrual Dysphoric Disorder (PMDD) PMDD was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. A woman with PMDD has severe symptoms of depression, irritability, and tension about a week before menstruation begins. Common symptoms include mood swings, irritability or anger, depressed mood, and marked anxiety or tension. Other symptoms may include decreased interest in usual activities, difficulty concentrating, lack of energy or easy fatigue, changes in appetite with specific food cravings, trouble sleeping or sleeping too much, or a sense of being overwhelmed or out of control. Physical symptoms may include breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. These symptoms begin a week to 10 days before the start of menstruation and improve or stop around the onset of menses. The symptoms lead to significant distress and problems with regular functioning or social interactions. For a diagnosis of PMDD, symptoms must have occurred in most of the menstrual cycles during the past year and must have an adverse effect on work or social functioning. Premenstrual dysphoric disorder is estimated to affect between 1.8% to 5.8% of menstruating women every year. PMDD can be treated with antidepressants, birth control pills, or nutritional supplements. Diet and lifestyle changes, such as reducing caffeine and alcohol, getting enough sleep and exercise, and practicing relaxations techniques, can help. Premenstrual syndrome (PMS) is similar to PMDD in that symptoms occur seven to 10 days before a woman’s period begins. However, PMS involves fewer and less severe symptoms than PMDD. Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder is a condition that occurs in children and youth ages 6 to 18. It involves a chronic and severe irritability resulting in severe and frequent temper outbursts. The temper outbursts can be verbal or can involve behavior such as physical aggression toward people or property. These outbursts are significantly out of proportion to the situation and are not consistent with the child’s developmental age. They must occur frequently (three or more times per week on average) and typically in response to frustration. In between the outbursts, the child’s mood is persistently irritable or angry most of the day, nearly every day. This mood is noticeable by others, such as parents, teachers, and peers. In order for a diagnosis of disruptive mood dysregulation disorder to be made, symptoms must be present for at least one year in at least two settings (such as at home, at school, with peers) and the condition must begin before age 10. Disruptive mood dysregulation disorder is much more common in males than females. It may occur along with other disorders, including major depressive, attention-deficit/hyperactivity, anxiety, and conduct disorders. Disruptive mood dysregulation disorder can have a significant impact on the child’s ability to function and a significant impact on the family. Chronic, severe irritability and temper outbursts can disrupt family life, make it difficult for the child/youth to make or keep friendships, and cause difficulties at school. Treatment typically involves psychotherapy (cognitive behavior therapy) and/or medications. Persistent Depressive Disorder A person with persistent depressive disorder (previously referred to as dysthymic disorder) has a depressed mood for most of the day, for more days than not, for at least two years. In children and adolescents, the mood can be irritable or depressed, and must continue for at least one year. In addition to depressed mood, symptoms include: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness Persistent depressive disorder often begins in childhood, adolescence, or early adulthood and affects an estimated 0.5% of adults in the United States every year. Individuals with persistent depressive disorder often describe their mood as sad or “down in the dumps.” Because these symptoms have become a part of the individual’s day-to-day experience, they may not seek help, just assuming that “I’ve always been this way.” The symptoms cause significant distress or difficulty in work, social activities, or other important areas of functioning. While the impact of persistent depressive disorder on work, relationships and daily life can vary widely, its effects can be as great as or greater than those of major depressive disorder. A major depressive episode may precede the onset of persistent depressive disorder but may also arise during (and be superimposed on) a previous diagnosis of persistent depressive disorder. Source: Diagnostics Statistical Manual Version 5 - Treatment Review (DSM5-TR)

Stephen M. Strakowski, MD: Hello, and thank you so much for turning into our conversation today. I’m excited to have Dr Sheri Johnson here to talk about bipolar disorder in a different way than we typically do. Dr Johnson is a distinguished professor at the University of California Berkeley and is truly the world’s expert in reward processing in bipolar disorder and mania, which is the conversation today. Dr Johnson, welcome. Sheri L. Johnson, PhD: Thanks so much for having me. Looking forward to our conversation. What Does “Reward Processing” Mean in Bipolar Disorder? Strakowski: Today we want to talk about reframing of bipolar disorder from a mood disorder to a reward processing disorder. To kick it off, I want to share one slide that I’ll have Dr Johnson walk us through here in a second. It reflects a lot of the work that she’s done and is from a review article by Nusslock, Mittal, and Alloy from 2025 that’s talking about reward processing in bipolar disorder and depression, and I think schizophrenia in this one too. So, Dr Johnson, what are we talking about when we’re saying we need to rethink bipolar disorder as a reward processing disorder? Johnson: Sure. This is a beautiful article by Robin Nusslock and his colleagues going over decades of theory and research. Let’s start by taking on what we mean by reward processing. All of us have systems in our brain to help motivate us. We have a threat and punishment motivation system that helps us get away from bad things. We also have a motivational system that helps us move towards great opportunities and good things that could happen. And so, this system helps us move towards anything from a great piece of chocolate, love, job accomplishment, ways to find ourselves being admired, liked, and all the goodies in life. The great thing is that we all have one of these. We all have a brain system that helps us move towards the good things. The idea here for people with bipolar disorder is that the system is somehow hypersensitive and once it comes online, it tends to stay online a little bit too long, a little bit too high. What does that do for us? One is it taps into a large body of the brain science of reward systems in the brain, but it also tells us a lot about ways in which we think mania unfolds over time and the early signals of risk for mania and bipolar disorder. Is Reward Hypersensitivity Specific to Bipolar Disorder? Strakowski: Is this hypersensitivity to reward unique in bipolar disorder, or does it happen in other conditions? Johnson: There are many different conditions that seem to involve some differences in reward sensitivity, and that’s part of what I’ve been interested in now for a couple decades. Is there something more specific about what it looks like in bipolar disorder? I think there really are two strands that are unique and specific in bipolar disorder. One is a tendency to set high goals and to go after goals even when the rewards might be pretty minor. People with bipolar disorder will describe themselves as being sensitive to rewards on self-report, if you ask them self-report questions, they’ll say, “Yeah, I am like that. When there’s a small opportunity for reward, I get more excited, more motivated than other people.” That can predict the onset and course of mania over time. But we think another thing it does is it leads them to set pretty high life goals and to be more ambitious and more willing to spend effort on going after and chasing those goals. So that’s one whole piece of this puzzle that’s fascinating to me. Sometimes it has good sides. Sometimes it can predict more mania over time, but sometimes it actually helps people and their family members do a little bit more. High Goal Setting and the Drive Toward Mania Johnson: There’s another piece here in bipolar disorder that I’m really interested in though. Once people click into the process of going after a goal (what we call “goal pursuit”) and they get immersed in that I’m going after the goal, I’m going after the dream, they can get a little dysregulated, overly confident, and start to take some risks that they wouldn’t otherwise do. Often, when they come back out of that period, they feel really a sense of remorse, a sense of loss of like Hey, how did I end up doing that? That’s not something I would’ve normally done. It’s as though the whole thermometer went up a little bit and they were just acting with the only thing in view was I’m going for it. I’m going for the gold. Strakowski: We have a tendency, particularly in the Western culture, but certainly in the United States, that we set that moods are goals. So, “life, liberty and the pursuit of happiness,” is a goal. But when I think about moods and emotions, the brain is firing off signals to try to motivate us to do things. If we think about it that way, does that somehow link the mood states of mania with this? How would you think about it? Johnson: For all of us, when we feel like we’re going after a dream or a goal, something that we would really value, when we’re making progress towards that, it’s exciting. That excitement helps us mobilize our energy, our movement, our thinking, that sense of, Okay, I’m on fire. All of us have the capacity for some part of that. We just think the volume has turned a little higher for the person with bipolar disorder. Does Euphoria Create a Self-Reinforcing Cycle? Strakowski: Yeah, that’s what I’ve wondered. The euphoria would be your brain saying, “Keep doing what you’re doing,” and that would drive you to continue reward processing, which would drive more euphoria. It just feels like a vicious cycle that might land people in a manic state. Is that reasonable? Johnson: That is a lot of how I think about it. I also think that part of what happens for most of us is that we can be really excited about our dream, but we have a really nice, strong signal from our body that it’s time to go to sleep, pipe down, and pick it up in the morning. But if you have weekday and weeknight rhythms to begin with, which often happens for somebody with bipolar disorder, and you don’t have that strong body signal of, come on, you’re tired, go to sleep, pick it up in the morning. You can end up working on that dream and the goal through a large part of the night and get more dysregulated and have less of a break on the whole system. Creativity, Success, and Genetic Risk Strakowski: Very interesting thought. The other thing you kind of alluded to - if this personality trait or feature is present genetically, which is implied and as we know, things like creativity, charisma, success, run in bipolar families at higher rates than general population are you posing that perhaps it’s being expressed at different levels to the point of illness in some of the members but to great success in others? Johnson: I’m fascinated by that question and I’m really glad you asked it. We do know that reward sensitivity is fairly heritable - it runs in families. We’ve looked at how this then relates to the creative accomplishments in people with bipolar disorder. Simon Kyaga, MD, PhD, MBA, has done beautiful analyses of the entire population of Sweden to show that people with bipolar disorder, but more so their family members who’ve never had a mania, tend to be very creatively accomplished. They’re more likely to be paid as artists, more likely to be university professors, more likely to become entrepreneurs, and the family members who are entrepreneurs tend to make more money in business startups. So, all these signals of creativity running in the family. We’ve done a set of studies to say, “What is that? What’s the magic juice there?” and one of the things we see is that willingness to work hard for a small reward is correlated with the creative accomplishment. People who are being paid as artists or creative people tend to have higher levels of that, Yeah. I’ll work really hard for a small reward. Sadly, the life of an artist right now is that you work really hard for tiny signals of recognition for most of the career. So, we think that that kind of willingness to work really hard for a small reward is probably a great thing for creativity. Now, the good news that I want to highlight is that you don’t need mania for that creativity to come through. The creativity is there in family members who have never had an episode of mania. I think something about that high level of reward pursuit, high levels of willingness to work hard that’s coming through, being carried in these families, is a huge advantage and that advantage is particularly there if we can protect people from all the difficulties that come along with mania. Trait vs State: Is Reward Sensitivity Always Present? Strakowski: The other thing that you had mentioned as you were talking about this constant high goal setting is that maybe this isn’t just occurring during mania, but is a trait present all the time, which is a genetic condition one would imagine is true. Do you believe that’s true? Johnson: Yeah, but I think the form changes so we can ask people when they’re fully well between episodes, “Do you tend to set higher goals in your life than other people?” People will endorse very high goals, really wanting to make a huge difference in life, like make millions of dollars, be the subject of books or TV shows, be a leader. People will often have ideas of like, I’d like to be one of the people that engineers world peace or climate change. Big meaningful goals. They also hold themselves to really high standards. We’ll sometimes see a kind of strand of perfectionism of, I don’t want to do a bad job on this goal. But that is often quietly in the background. So many of the people we work with will say, “Yeah, that’s there, but I don’t talk about it much. It’s just a hope. It’s just a dream.” But then when the mania kicks in, they tend to get very immersed in going after those goals and dreams and that’s when they stop sleeping as much, they may be spending more money than they wanted to, and they’re taking on that goal in a way that sometimes is painful because it’s too big, it’s too ambitious, it’s too much. I always think, Okay, having a big dream is great. Steve, you and I want to make a difference in the world of bipolar disorder. That’s a really hard and difficult dream. Nobody is going to criticize us for having a big dream and hope. The key is that as people get manic, it becomes very hard to modulate how intensely and how calibrated the work of goal engagement is. Clinical Implications of a Reward-Based Model Strakowski: We might think about as the reward pursuit events occur, it drives a euphoric mood state, which are elevated, and the transition keeps cycling until it’s euphoric and then we have mania on something that’s always present. That’s the idea that this is a reward processing condition rather than a primary mood disorder. How would that be applied to thinking about treatment? Does it change anything we commonly do, or would there be new models we might think about in our practices? Johnson: Yeah, it does change things. We’ve done a little bit of treatment development - very exploratory work. At the biological front, my hope is that we’ll develop precision medicine approaches that help with that process. I don’t think we’re quite there yet, but that’s the hope. But for now, since we don’t have that in hand, the hope is that we can help psychologically. One piece that we’ve had good luck with is just helping people with bipolar disorder understand this process. Helping them understand that they might be somebody who harbors higher goals than other people. I’ve often been surprised during that conversation that people with bipolar disorder won’t see their goals as particularly high. They don’t see themselves as hard driving. They just think like, Well, of course, doesn’t everybody hold to that kind of life ambition? They’re sometimes surprised to hear, “Yeah, no. Other people are not wandering around thinking about making a difference in world peace or changing bipolar disorder or doing other kinds of things like that.” I’m never going to criticize those goals, but I want them to be very self-compassionate when you can’t change something that big. The other part that we work very hard on is recognizing the early signs of getting too goal engaged, too overly confident, starting to do the risk taking, and thinking about ways to retreat and give a break to the goal pursuit in that moment. Goal pursuit is an elixir. It makes everybody excited. Pull back, make sure you can take some breaths, make sure you can sleep through the night. If this is really a game changing, beautiful goal idea, it’ll still be there. It’s almost never in life where you have to seize the day immediately for this to work in the big picture. So, giving people ways to test the breaks and recognize the signals that they’re moving into one of those periods. Helping Patients Regulate Goal Pursuit Strakowski: It feels like cognitive behavioral therapy, where we start learning how to ratchet back a little bit when we get too high. Is that sort of how you all frame it when you work on it? Johnson: I always talk about the idea of testing the brakes. It’s very hard to stop a car when it’s going full tilt, but if you start to feel the car having momentum, that’s the time to tap the brakes and make sure they’re working. Strakowski: You and I have been talking about this and working on it, and I think it’s an interesting way to reconceptualize the illness and also to think about some alternative treatment development pathways, and so we’re excited and hope that other people will think about this. I’ve talked to a number of the people I treat and work with bipolar disorder, and it really seems to resonate with them. I don’t know if you’ve had that experience too, but they say, “That really feels like me in a way that mood changes didn’t.” Does that make sense? Johnson: When we’ve written about this, I’m always struck by how many people will then contact me to say, “I think you’re on track.” That’s the heart and soul of why we want to do this. We want something that fits for people with the disorder. Strakowski: Well, thank you. Like we said, we’re very excited about this as a new model that might help advance certainly the psychotherapeutic side of bipolar disorder, and as Dr Johnson mentioned, thinking about how we personalize things. Hopefully, all who are tuned in and listening to this find it also invigorating. Ask some of your patients and see what they think about it. We appreciate very much you are taking the time to sign into Medscape. I’m Steve Strakowski and thank you very much. Stephen M. Strakowski, MD, is the professor and vice chair, Research of Psychiatry at Indiana University School of Medicine, and a professor at the Department of Community and Global Health at the Richard M. Fairbanks School of Public Health at Indiana University in Indianapolis, Indiana. He also serves as professor of psychiatry and associate vice president, Regional Mental Health at the Dell Medical School, University of Texas in Austin. In addition, Strakowski is editor-in-chief of the Journal of Mood and Anxiety Disorders. Sheri L. Johnson, PhD, is a professor of psychology at the University of California Berkeley and renowned for her expertise on bipolar disorder. She is also the Cal Mania (CALM) program director, where she leads research surrounding emotion and impulsivity. Note: This article originally appeared on Medscape.

In recent years, magic mushrooms, a colloquial phrase for fungi containing the hallucinogenic chemical psilocybin, have progressed from a counterculture curiosity to a significant psychiatric study topic. Scientists and physicians are now looking into whether psilocybin assisted therapy could be a new paradigm for treating mental illnesses, particularly those that are resistant to traditional therapies. What are Magic Mushrooms? Magic mushrooms contain psilocybin, a naturally occurring psychedelic chemical that, when consumed, is transformed to psilocin in the body. Psilocin predominantly interacts with serotonin receptors in the brain, specifically the 5-HT2A receptor, resulting in altered perception, mood, and cognition. Unlike daily psychiatric medications, psilocybin is usually given in supervised professional settings, sometimes alongside psychotherapy, in one or two sessions rather than as a long-term treatment. Mental Health Crisis and the Need for New Treatments Depression, anxiety, post-traumatic stress disorder (PTSD), and addiction continue to pose significant worldwide health issues. A large proportion of patients, particularly those with treatment-resistant depression (TRD), do not react well to traditional therapies such as SSRIs or cognitive behavioral therapy. How Does Psilocybin Work in the Brain? While research continues, various pathways may explain psilocybin's therapeutic effects: 1. Disrupting rigid thought patterns Mental diseases, such as depression, are frequently accompanied with persistent negative thinking and rigid cognitive patterns. Psilocybin appears to temporarily interrupt these patterns via influencing activity in the brain's default mode network (DMN), a system associated with self-referential thinking. This disturbance may allow patients to "reset" their maladaptive mental habits. 2. Increasing Neuroplasticity. Psilocybin may increase neuroplasticity, or the brain's ability to build new connections. Preclinical and imaging research indicates that psychedelics can: Increase connections between brain areas. Enhance emotional learning. Support behavioral change. This may explain why patients frequently experience long-term psychological changes following treatment. 3. Facilitating Emotional Processing. Psilocybin use frequently results in strong emotional and introspective states. This can happen in therapeutic environments. Help patients deal with unresolved trauma. Increase your emotional openness. Encourage acceptance and meaning-making. Trained therapists often guide this procedure to guarantee safety and integration. The role of psychotherapy It is critical to note that psilocybin is not utilized in isolation in clinical study. Psilocybin-assisted psychotherapy is a structured model that includes: Preparation sessions: developing trust and defining expectations. Dosing session: supervised psychedelic experience. Integration sessions: involve absorbing insights and applying them to everyday life. The treatment setting is regarded as critical for both safety and effectiveness. Risks and Limitations Despite promising results, psilocybin therapy does not come without hazards. Psychological Risks Severe anxiety or panic ("bad trips") Temporary bewilderment or paranoia. Possible exacerbation of psychosis in vulnerable patients. Medical and Research Limitations Most studies use tiny sample sizes. Long-term safety evidence are scarce. Effects may vary widely across individuals. Additionally, psilocybin is still a restricted substance in many nations, limiting access outside of clinical trials. Magic mushrooms, which were formerly considered as recreational drugs, are today at the forefront of psychiatric innovation. Early research suggests that psilocybin-assisted therapy may provide significant and long-term relief for depression and anxiety, especially in patients who have not responded to standard therapies. However, this field is still developing. While the results are promising, psilocybin is not a cure-all, and its safe and effective usage requires controlled surroundings, expert supervision, and ongoing scientific rigor. As research continues, psilocybin may revolutionize how we study and treat mental illness, changing the emphasis from symptom treatment to genuine psychological change.

Supporting a loved one with bipolar disorder can be emotionally hard, difficult, and often overwhelming. Families frequently find themselves managing unpredictable mood swings, ranging from manic highs to depressive lows, while attempting to preserve everyday stability. Understanding the disease and understanding how to respond successfully are critical not just for the individual diagnosed, but also for the overall well-being of the family system. Bipolar disorder is a chronic mental health disorder marked by severe mood swings, including mania, hypomania, and depression. These events have the potential to influence behavior, decision-making, sleep patterns, and interpersonal relationships. What is The Emotional Impact on Families Caring for someone with bipolar disorder can trigger a wide range of emotions, including concern, irritation, guilt, and even burnout. During severe episodes, family members may feel helpless and unsure of how to provide appropriate support. It is critical to recognize that these responses are valid. Supporting a loved one with a chronic illness necessitates patience, adaptability, and resilience. However, neglecting your own mental health during the process might result in caregiver weariness, limiting your ability to provide effective support. Common Early Warning Signs of Bipolar Disorder Each individual with bipolar disorder has a unique set of triggers. Stress, sleep disruption, substance abuse, and major life changes are all possible causes. Families that recognize these factors can help prevent crises from escalating. Typical early warning signals include: Sleep patterns change. Increased irritation or restlessness. Sudden fluctuations in energy or motivation Withdrawal from social interactions Recognizing these symptoms early enables for timely response, such as changing routines or seeking professional help. While support is necessary, it is also critical for families to set boundaries. Supporting someone with bipolar disorder should not imply accepting damaging conduct or ignoring your own needs. Boundaries promote a balanced dynamic in which assistance does not lead to over-dependence or emotional exhaustion. Are Early Symptoms Different in Men and Women? Early symptoms of bipolar disorder can change between men and women, but the basic diagnostic markers stay the same. Men are more likely to develop the illness younger, usually in late adolescence or early adulthood, and it begins with more obvious manic or hypomanic episodes. These may include increased energy, risk-taking behavior, impatience, and impulsivity, all of which can be mistaken as personality qualities rather than symptoms of a mood disorder . On the other hand, women are more likely to appear with depressive symptoms at first, such as chronic sorrow, exhaustion, changes in sleep and food, and feelings of guilt or worthlessness. Women are also more likely to experience rapid cycling patterns, in which mood episodes change more frequently, and they may be more sensitive to hormonal effects such as menstrual cycles, pregnancy, or menopause. Furthermore, co-occurring conditions like as anxiety disorders are more common in women and can disguise or overlap with early bipolar symptoms. These gender-related patterns are not absolute, but they are clinically significant because they affect how quickly the illness is diagnosed and treated. Hope and Long-term Stability Although bipolar disorder is a lifelong diagnosis, it can be managed with the correct combination of medication, support, and lifestyle changes. Many people have secure, prosperous lives thanks to their informed and supportive families. Progress may not always be linear, and setbacks are possible. Long-term stability, however, is within reach with patience, perseverance, and competent assistance. Supporting a loved one with bipolar disorder requires a careful balance of empathy, structure, and self-knowledge. Families play an important part in the rehabilitation process, but they must also realize their own limitations and seek help as needed.