Key Takeaways Emergency psychiatry involves complex legal and ethical issues, including patient privacy, autonomy, and safety, requiring careful navigation of HIPAA regulations and ethical principles. Pediatric confidentiality adds complexity, necessitating transparent communication with patients and caregivers about confidentiality limits and safety concerns. Involuntary hospitalization and high-risk discharges require balancing autonomy with beneficence and nonmaleficence, ensuring patient safety and appropriate care. Initiating acute treatment in emergency settings is crucial, with informed consent challenges and the need for flexibility in applying legal and ethical considerations. S PECIAL REPORT: EMERGENCY PSYCHIATRY Emergency psychiatry faces several unique legal and ethical issues given the high stakes of assessing acute lethality, determining disposition often with incomplete information, and interfacing with external stakeholders. The Health Insurance Portability and Accountability Act (HIPAA) often causes legal concerns for clinicians when deciding whether confidentiality can be breached over a patient’s objections. Working with pediatric patients old enough to consent to their own mental health treatment and who ask for privacy adds another layer of complexity. Ethical issues in emergency psychiatry include thoughtful consideration of autonomy, beneficence, and nonmaleficence as they pertain to clinical decision-making, high-risk discharges, initiation of treatment in the emergency setting, and use of restraint and/or seclusion. This article will review key practice points for each of these considerations. Balancing Patient Privacy and Collateral Despite HIPAA’s privacy exceptions, the decision to contact sources of collateral information over a patient’s objection can be a difficult one. Providers may hesitate even to accept information from others. After mass shootings in Aurora, Colorado, and Newtown, Connecticut, in 2012, the Office of Civil Rights released a letter addressed to “our nation’s health care providers” reminding them of privacy exceptions. The letter outlined that clinicians are “presumed to be acting in good faith” if they base their opinion on either direct knowledge or a “credible report from a family member of the patient or other person” and can release information to individuals (eg, family) or entities (eg, law enforcement) who can help mitigate danger posed by the patient to themselves or others. If someone calls with a concern, clinicians can accept information and integrate it into the assessment without releasing information. Disclosures should be limited to the minimum needed to mitigate risk. Patients may not express suicidal or violent intent on interview for a variety of reasons. In fact, Shea wrote in 2009 that “real suicidal intent” equals “stated intent + reflected intent + withheld intent.” A careful interview is essential, but the last 2 elements may hold the key to an accurate assessment. In 2021, Edwards et al acknowledged the critical importance of collateral information regarding withheld intent in a review of the essential role of natural supports in suicide prevention. Collateral information from family or other sources can provide missing puzzle pieces of reflected and withheld intent, allowing for more effective interventions. Pediatric Confidentiality Considerations Clinicians face an ethical challenge when safety concerns involving children and adolescents arise, particularly if these patients have concerns about their parent or guardian learning of these concerns. When individuals present with suicidal or homicidal ideation, self-harm, or other safety concerns, they must undergo a thorough risk assessment, which includes interviewing caregivers. This evaluation may be the first time parents or guardians learn about the child’s emotional distress. Clinicians should be transparent with the individual from the beginning of the interview about the limits of confidentiality, including suicidal and homicidal ideation and alleged abuse. If the adolescent resists sharing safety-related concerns with their parents, the provider should explore these feelings collaboratively and discuss the specific information that will be shared with the parent/guardian. Clinicians can ask the patient how they expect their parent/guardian to react and reassure them that support will be offered during this difficult conversation. It helps to acknowledge and validate that discussing topics such as lethality and self-harm may be uncomfortable but that it is a necessary part of the evaluation process and disposition planning. Creating a space for emotionally safe disclosure is the clinician’s responsibility, ensuring that parents/guardians are informed and can actively participate in safety planning, risk mitigation, and decisions about next steps in care. Health systems face challenges with protecting adolescents’ mental health and substance use information, given that parents may have proxy access to their child’s electronic medical record. In addition, some states have passed a Parents Bill of Rights act, which curtails confidentiality, consent, and privacy rights for adolescents. States also vary on the age required to consent for mental health and substance use treatment. Balancing Autonomy With Beneficence and Nonmaleficence Another common issue that emergency psychiatric clinicians face is the need for involuntary psychiatric hospitalization of patients at imminent risk of self-harm, harm to others, or self- impairment. In many cases, patients will present to emergency services or crisis settings requesting voluntary admission, which is typically legally and ethically straightforward.7 However, there are cases in which it may not be ethically advised to pursue a voluntary admission, even at the patient’s request, as in a patient with secondary gain using the hospital to avoid social stresses or a patient with personality characteristics that have led them to externalize coping in inpatient psychiatric settings as opposed to developing necessary distress tolerance skills. In these cases, clinicians may experience the tension of autonomy vs nonmaleficence, whereby they try to decrease potential iatrogenic harms from patient-requested psychiatric admissions. More commonly, emergency psychiatric clinicians face the issue of patients with limited insight and dangerously impairing symptoms who need to be hospitalized against their wishes. This tension of autonomy vs beneficence, or the need to override the patient’s wishes to do what is medically appropriate, can be difficult but is medically and ethically necessary. In these cases, guaranteeing that clear evidence and indication exist to ensure the patient’s safety and well-being is critical in navigating this ethical tension. There is variance in involuntary commitment criteria between states. Psychiatrists and mental health clinicians should be aware of local involuntary commitment guidelines and procedures. If it is unclear whether involuntary commitment is legally appropriate, providers can consult with the hospital’s legal team. High-Risk Discharges Some patients may clearly benefit from inpatient admission but are unwilling to voluntarily consent, without involuntary commitment grounds being present. In these cases, providers should obtain collateral, thoughtfully discuss and document decision-making, and mitigate modifiable risk factors, eg, via safety planning and reducing access to lethal means. Evidence shows safety plans can help reduce suicidality and improve treatment outcomes. Some patients are at chronically elevated risk of lethality, such as those with repeated suicidal behaviors or a history of violence, who are frequently seen in the emergency psychiatric setting. At times, an acute inpatient psychiatric admission may not be clinically warranted and may actually be countertherapeutic. Clinicians often worry about the risk of adverse patient outcomes and associated litigation, as well as conversations with a patient’s supports on the rationale for discharge. Key components should include engaging the patient and their supports in safety planning and discussing the diagnostic formulation and appropriate treatment options/referrals. Consultation with colleagues, leadership, risk management, and/or legal counsel can be helpful. Organizations can consider patient care plans to help more cohesively care for patients with frequent presentations. Lastly, some patients present with contingency-based suicidal threats. Results of studies have shown that patients who present with contingency-based threats do not appear to be at elevated risk of suicide, although they may have increased emergency department (ED) presentations for self-harm. Bundy et al write that effective documentation surrounding discharge of patients with contingent lethality should contain 6 important items. Initiating Acute Treatment In our current landscape of prolonged boarding for inpatient psychiatric beds, treatment should ideally be initiated in the ED setting and not be deferred to the inpatient teams, as it would for patients presenting with other emergent conditions. Treating substance withdrawal is critical, given the risks of complicated withdrawal (eg, with GABA-mediated agents) and of patients leaving against medical advice. Home medications should be continued in the emergency setting, as missing medications may worsen a patient’s psychiatric symptoms, place them at risk of withdrawal, and/or otherwise negatively affect their health. Patient harm can occur because of the withholding of home medications. At times, obtaining informed consent before initiation of medication or other treatment can be difficult if a patient presents with severe symptoms and lacks decision-making capacity. Capacity has 4 components: (1) expression of a clear and consistent choice, (2) understanding of factual information, (3) ability to manipulate information to make decisions, and (4) appreciation of the current situation and consequences of a choice. Preferably, patients are involved in decisions about medications, including specific agents and routes of medication, thus promoting their autonomy. However, if a patient’s conduct is placing themselves or others at more imminent risk, even if a patient is not providing consent for treatment, beneficence may outcompete patient autonomy. Similarly, patients who refuse treatment after a significant overdose would likely necessitate treatment over objection. In these cases, pursuing an involuntary commitment may be warranted. In nonemergent situations, states differ on what is necessary to provide treatment over objection, so providers should be aware of their individual state laws. Restraints and Seclusion Workplace violence is on the rise, particularly in emergency settings, so early identification of and intervention for escalating agitation are of the essence in maintaining patient, visitor, and staff safety. Many factors can contribute to patient/visitor agitation, including prolonged boarding, unclear wait times or expectations, overstimulation, lack of interaction or structured activities, substance intoxication/withdrawal, and acute psychiatric conditions. As physical interventions increase the risk of patient and staff injury, general principles for agitation management include engaging the patient in verbal de-escalation (including choice of medications) and attempting less restrictive interventions. Organizations can proactively work toward critically appraising and modifying their environments (eg, improving screening of contraband/weapons), and available resources/personnel can provide robust training on verbal de-escalation and physical interventions, ideally via simulation-based education. Because patients and families may pursue legal action for patient injury from a restraint, it is imperative that a restraint technique be continuously re-evaluated with coaching and correction provided. Given disparities in agitation management in the emergency setting, providers should critically appraise the impact of bias in their perception of agitation, which may be partially mitigated via validated agitation rating scales. Although verbal de-escalation and other nonrestrictive interventions are first-line recommendations, as boxer Mike Tyson said, “Everyone has a plan until they get punched in the mouth.” Staff are compelled to immediately intervene when there is imminent risk or assaultive behavior. If restrictive interventions are required, teams should debrief afterward and work toward discontinuing these interventions once it is safe. Concluding Thoughts By the nature of their work, emergency psychiatrists balance various legal and ethical principles in evaluating and caring for patients, such as privacy, autonomy, beneficence, and nonmaleficence. Clinical scenarios are unpredictable and often evolve rapidly, so providers must be cognitively flexible and agile in applying the various legal and ethical considerations presented in this article. Note: This article originally appeared on Psychiatric Times .

Key Takeaways Improved or sufficient sleep enhances antidepressant response in TRLLD, while persistent insufficient sleep predicts treatment nonresponse. The OPTIMUM trial found no difference in sleep improvement between treatment arms, emphasizing the importance of addressing sleep disturbances. Behavioral interventions like sleep hygiene and CBT-I are recommended for managing sleep issues in older adults with TRLLD. Sedative hypnotics pose risks, and alternative strategies, including low-dose mirtazapine or doxepin, are suggested for sleep management. Patients with treatment resistant late-life depression (TRLLD) were found 3 times more likely to respond to augmenting or switching antidepressant treatments when sleep also improved or sufficient sleep was maintained, in a post-hoc analysis of a trial comparing interventions. “Sleep-related symptoms that are present during treatment for TRLLD may be modifiable factors that play a role in achieving and maintaining depression response,” observed Michael Mak, MD, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, and colleagues. The investigators revisited data from the Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM) trial which compared pharmacotherapeutic strategies for TRLLD, to ascertain whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, or with improved sleep. Mak and colleagues hypothesized that the analysis would show that (1) most participants with TRLLD exhibit reduced sleep, (2) sleep would improve with each of the pharmacotherapeutic strategies, and (3) that improved sleep would be associated with improvement in depression symptoms, while depression would remain treatment resistant if insufficient sleep persisted or worsened. The OPTIMUM trial treatment arms either augmented the current antidepressant with aripiprazole or bupropion, or switched to bupropion; if symptoms did not remit, investigators augmented with lithium or switched to nortriptyline. Depression symptom severity was measured with Montgomery-Asberg Depression Rating Scale (MADRS), with remission defined as a score less than 10. The MADRS sleep item-4 measured insufficient sleep, comparing duration or depth of sleep during treatment for depression with the pattern when well. Adequacy of sleep is rated on a scale of 0 to 6 with higher scores indicating greater sleep disturbance. In the analysis, a score of greater than 2 at both week 0 and week 10 was classified as persistent insufficient sleep (n=164). Scores that increased over the course of treatment and were greater than 2 at week 10 corresponded to worsening sleep; and a decreased score that was less than or equal to 2 at 10 weeks corresponded to improved sleep. Those with scores of less than or equal to 2 at each visit were categorized as having persistent sufficient sleep and served as the comparator group. Insufficient sleep was reported by 51% of participants (n=323) at the start of the trial.They tended to be younger, had fewer years of education, and had higher severity of depression than those with sufficient sleep. At the end of the initial 10-week switch or augmentation treatment, the number of participants reporting insufficient sleep had fallen to 36%, with no associated difference between treatment arms. Mak et al determined that those with persistent insufficient sleep (25%, n=158) and worsened sleep (10%, n=62) were most likely to remain unresponsive to antidepressant treatment. Those who maintained sufficient sleep (26%, n=164) or had improved sleep (25%, n=158) were 3 times more likely to experience improvement in depression, regardless of the switch or augmentation strategy. Independent predictors of treatment nonresponse included persistent insufficient sleep and worsened sleep. The investigators found that approximately one-third of the participants were using sedative hypnotics for sleep or anxiety. They suggest that the risks associated with these medications are likely to outweigh their benefit, even when used for their approved indications. "As such, the treatment plan should include education about the risks of benzodiazepine use in older adults and healthy sleep behaviors, pharmacologic treatment of insomnia or reduced sleep when appropriate, or referrals to behavioral interventions for sleep," Mak et al urge. Accounting for Sleep in Treating Resistant Depression Having associated sufficient and improved sleep with antidepressant response in TRLLD, the investigators considered the long-established bidirectional relationship of sleep disturbance and depression, and implications for treatment. "In most patients, treating the depression with an evidence-based antidepressant is enough to treat all symptoms including the insomnia," study coauthor Benoit Mulsant, MD, Department of Psychiatry, University of Toronto, explained to Psychiatric Times. The association of sufficient sleep with improvement in depression in each of the treatment arms, regardless of using an "alerting" or less sedating antidepressant like bupropion, is notable, Mulsant observed. "Trying to match patient's symptoms (eg insomnia) with adverse effects of a specific antidepressant (eg sedation) does not work," Mulsant commented, citing previous trials."Patients with depression and insomnia do not do better when randomized to a sedating tricyclic antidepressant than to an activating one like bupropion." However, Mulsant acknowleged that sleep disturbance that precedes and persists after onset of depression can require separate attention. "In a subgroup of patients with depression, insomnia predates depression and does not resolve with resolution of other symptoms, so it is important to assess and treat sleep symptoms with sleep hygiene or CBT-I when needed," he suggested. Lead-author Mak elaborated on the approach for these patients. "If a patient with TRLLD still complains of sleep disturbance/insomnia disorder post-antidepressant treatment, they should trial sleep hygiene therapy and CBT for insomnia if available. The residual insomnia is a substantial risk factor for recurrent depression," Mak warned. In their post-hoc analysis of the OPTIMUM trial, the investigators found that loss of a spouse and lower levels of education were risk factors for having sleep disturbance. For these and others at-risk for or experiencing persistent disrupted sleep, the investigators supported particular attention to sleep in managing their depression. "These patients would still be good candidates for sleep hygiene or CBT-I, if needed, Mulsant indicated. "A first-line antidepressant can be augmented with a medication specifically targeting sleep. A good one for older patients would be mirtazapine at low dosage, like 7.5 or 15 mg, because at higher dosage it becomes a sedating antidepressant that many patients do not tolerate." Mak agreed with the recommendation, adding that patients with mild insomnia may benefit from adding low dose doxepin, 3 to 6 mg, at bedtime to buttress sleep maintenance. "Safety outcomes for low dose doxepin in older adults is reassuring," he commented. Mulsant cautioned that additional evaluation may be warranted in some patients presenting with TRLLD accompanied by poor sleep, fatigue, and cognitive impairment for an undiagnosed sleep apnea or a rarer sleep disorder. Mak concurred. "If an elderly treatment resistant depression patient has co-morbid snoring and/or BMI 35 or above, they should be referred for polysomnograpy—given intermediate to high pre-test probability for obstructive sleep apnea. Male sex, sleepiness or fatigue, presence of hypertension, witnessed apnea, and thick neck makes the risk even worse. Continuous positive airway pressure treatment may improve their mood in the context of obstructive sleep apnea.” Note: This article originally appeared on Psychiatric Times.

When I spoke at the International Society of Cosmetic Gynecology 2025 World Congress on March 21, I did not mention "cosmetics". Despite the organization’s focus on aesthetics, the unique skills of the members make them particularly suited to correct difficult problems regarding function — both urinary and sexual. These colleagues are adept at correcting conditions ranging anywhere from secondary anorgasmia to clitoral hood phimosis. At least half of their lectures focused on improving function, not aesthetics. I had been invited to speak about the use of formal dynamic systems theory and analysis to improve surgical outcomes. Systems analysis, a framework widely used to improve function in medicine, engineering, and business, can help us understand the complex — a word which most would agree could be used to describe the female orgasm. Understanding Systems in Medicine A system consists of interdependent components working together to produce an effect greater than any one part can produce. Systems medicine, an interdisciplinary approach, seeks to understand and manage complex biological interactions to improve health outcomes. By this definition, all 11 recognized body systems (integumentary, skeletal, muscular, nervous, endocrine, cardiovascular, lymphatic, respiratory, digestive, urinary, and reproductive) function as dynamic networks. Disruptions in one component will limit the function of the entire system. Of the 11, the female orgasm has a component overlap with the reproductive system — but they are not the same. A woman may conceive with anorgasmia, and a woman can also have a strong libido and enjoy multiple orgasms without conceiving a child. One may argue that the reproductive system provides offspring, but without the orgasm system there would be significantly fewer offspring. Yet, conceiving and sexual pleasure are not equal. One may also argue that if we need systems analysis to understand how to breathe and have a bowel movement, we should use system analysis to understand what brings joy and connection and creativity — orgasm. A 2023 study of medical education reported that out of seven medical schools in the Chicago area, only one taught the complete anatomy of the clitoris and how to evaluate female sexual dysfunction. Only one. As medical education starts to catch up with current research and women's legitimate demands for expert attention to their sexual concerns (by at least teaching physicians about comprehensive female anatomy), it may be time to acknowledge that, despite its absence thus far from traditional medical education, the female orgasm is complicated enough to warrant systems analysis, and such analysis first demands an attempt to define the system. If a "female orgasm system" exists, it should meet the same four criteria that define other systems: 1) identifiable components, 2) interdependent interactions, 3) emergent effects beyond any single component, and 4) stability across varied conditions. My efforts over the past 5 years to define the orgasm system and to encourage doctors and therapists to use systems analysis to treat female sexual dysfunction have not been an effort to invent anything; rather, I hope only to point out such a system exists and to offer a starting point for the work of others. Components of the Female Orgasm System To systematically describe female orgasm, we must first define its essential components. Primary Components Brain: The ultimate control center, integrating sensory, hormonal, and psychological inputs Breasts: Responsive to tactile stimulation, contributes to arousal, and affects pituitary function Clitoris: A sensory-dense structure that is integral to orgasm and communicates with the brain through both somatic and autonomic nerves. Labia: Provides protective and sensory functions Genitourinary Complex (GU Complex): Encompasses the vagina, urethra, and pelvic floor with both autonomic and somatic feedback to the arousal centers of the brain Endocrine System: Regulates hormonal influences on arousal and sexual response Spinal Cord and Blood Flow: Essential for neurological transmission, local engorgement, and relay of oxygen and hormones Psychosocial Factors: Emotional, cognitive, and relational influences that modulate the function of the entire body. Secondary Components Each primary structure comprises substructures with specific roles. For instance, the clitoris includes the glans, corpus cavernosum, and spongiosum. The GU complex involves vaginal elasticity and lubrication, while psychosocial factors extend to behavioral and linguistic influences. Feedback Loops in the Orgasm System: A Path to Innovation Dynamic systems operate through reinforcing and balancing feedback loops. In the context of female orgasm: Reinforcing Loops: Positive stimulation (physical or psychological) enhances arousal, further increasing blood flow and sensory feedback, culminating in orgasm. Balancing Loops: Psychological distress, endocrine dysfunction, or neurovascular impairment can counteract this reinforcement, inhibiting orgasmic function. Using systems analysis to consider how the feedback loops of the autonomic nervous system play a crucial role in female orgasm (integrating somatic input from the dorsal clitoral nerve with the autonomic pathways via the cavernous nerves, ganglion innervating the vaginal wall, inferior hypogastric nerve, and the vagus nerve) triggered the idea for the Clitoxin procedure to modulate autonomic input and enhance arousal. Clinical Implications for Treatment: A Systems-Based Diagnostic Framework Understanding an orgasm as a system provides a structured approach to evaluating sexual dysfunction. Consider a patient presenting with dyspareunia and anorgasmia following surgical intervention. First, surgical success does not guarantee orgasmic function. Although anatomical restoration is critical, persistent anorgasmia may stem from endocrine imbalances (eg, hyperprolactinemia, hypothyroidism), vascular limitations, or psychosocial stressors. Rather than relying solely on procedural interventions or sex therapy/counseling, comprehensive assessment and personalized, targeted, systemic corrections can optimize outcomes. Providers also should enhance patient communication and education.A visual model of the orgasm system can aid in counseling patients, emphasizing the multifactorial nature of the sexual response and reducing unrealistic expectations from isolated interventions. Let's Start Recognizing the Female Orgasm as a System When analyzed through the lens of systems medicine, the female orgasm provides a useful framework for refining surgical, medical, and psychosocial therapeutic strategies and for innovating new ideas. Recognizing orgasm as an emergent property of interconnected biological, neurological, and psychosocial factors fosters a more effective and sophisticated patient-centered approach and facilitates communication across specialties. Future research should continue refining this model to improve clinical applications and optimize sexual health outcomes. It is time for the twelfth body system — along with clitoral anatomy — to become part of our medical education. Note: This article originally appeared on Medscape .

TOPLINE: Attention-deficit/hyperactivity disorder (ADHD) in adults was associated with a higher risk for criminal behavior, especially in men and those with comorbidities such as alcohol use disorder. METHODOLOGY: This cross-sectional study included 308 patients diagnosed with ADHD (mean age, 34 years; 66% men) who were evaluated at a clinic in Italy between 2019 and 2024. Structured and semi-structured interviews along with standardized diagnostic tools, including the Adult ADHD Self-Report Scale and Diagnostic Interview for ADHD in Adults , were used. Crime-related and legal information was obtained through interviews with the participants. Factors such as sociodemographic characteristics, clinical variables, and criminal behavior were analyzed. TAKEAWAY: In all, 8% of participants were criminal offenders, and 92% of these were men. Prescription patterns revealed a significantly higher use of antipsychotics (61.4%) and antiepileptics (48.7%) among participants who committed crimes than among nonoffenders. Male sex was a significant predictor of criminal behavior (odds ratio [OR], 5.5; P = .03), as was alcohol use disorder (OR, 4.8; P = .001), in fourth model regression analysis. Oppositional defiant disorder was strongly associated with criminal behavior (OR, 5.3; P < .001). Combined ADHD presentation and unemployment were also potential risk factors for criminal behavior, but the associations were not statistically significant. IN PRACTICE: “The data from our study suggest that ADHD interacts with sociodemographic, emotional, and behavioral aspects, profoundly influencing the risk of encountering legal issues,” the authors wrote. “Specific screening programs for individuals with ADHD and their comorbidities can help identify at-risk individuals early and reduce their involvement with the judicial system," they added. SOURCE: This study was led by Martina Nicole Modesti, Department of Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy. It was published online on March 5 in International Journal of Law and Psychiatry. LIMITATIONS: The cross-sectional design of the study limited the ability to establish causal relationships between the variables analyzed and criminal behavior. The disproportionate subsample sizes of offenders and nonoffenders may have affected the generalizability of the findings. Any ongoing pharmacological treatments may have been potential confounding factors. In addition, reliance on clinical interviews for criminal history data may have introduced recall or concealment biases. The potential effect of dynamic environmental factors, such as family or working conditions, was not considered in the study. DISCLOSURES: The investigators reported having no relevant conflicts of interest. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. Note: This article originally appeared on Medscape .

Key points GLP-1 receptor agonists have been associated with multiple adverse psychiatric events. The drugs have been associated with depression, anxiety, insomnia, and suicidality. These correlations do not prove causality. More research on the topic is underway. In late 2017, the FDA approved the first and best-known GLP-1 receptor agonist, which you’ll probably know as “Ozempic.” At first it was only recognized as appropriate to treat Type 2 diabetes, but just over four years later, a 2 mg dose of the same drug received FDA approval for weight management. These medications then surged in popularity—according to a health tracking poll by KFF, as of May 2024 as many as 1 out of every 8 American adults had taken a GLP-1 drug. But by fall 2023, the system through which physicians notify the FDA of “adverse events” had already accumulated almost 500 reports of possible mental health side effects attributed to GLP-1 drugs. Anxiety, depression, and even suicidal ideation in patients had been reported by doctors across the country. NPR reported in September 2024 that in 96 of these adverse events, the patients in question had experienced suicidal thoughts; five of these patients died. To be clear, the FDA’s database is not designed for cause-and-effect reasoning, so it’s not possible to assign full responsibility for these serious psychological conditions to GLP-1 drugs. But a simultaneous groundswell on social media seemed focused on the same phenomena, as a 2023 study by the National Institute of Health documented (Arillotta et al., 2023). Data were collected from several social media websites, including TikTok, YouTube, and Reddit, and the resulting information was broken down via the use of an AI spreadsheet analysis platform called Numerous. Most social media comments pertaining to GLP-1 receptor agonists and psychological symptoms focused on “sleep-related issues, including insomnia,” but also called out “anxiety…depression…and mental health issues in general.” Again, some apparent links between weight loss medications and psychological side effects had been established, but without any clear causal link between them. Perhaps, for example, people who elect to use GLP-1 drugs are already more likely to experience anxiety or depression. Social media users also noted that the drugs also appeared to be losing their effectiveness over time, which could result in disappointment or in feelings of being “stuck"; thus, the researchers here may have found it hard to tease apart the drug’s potentially depressogenic consequences from the results of the drug’s failure to have its hoped-for effect. The next step was to perform another, bigger study, with more patients and more adverse events, collected over a larger period of time. Sure enough, a subsequent study of the FDA’s Adverse Event Reporting System was conducted, using a much larger sample. Last year, Chen, W. et al. reviewed 181,238 adverse event (AE) reports for psychological symptoms, then segregated 8,240 AEs as useful and relevant. This study found a “significant association” between GLP-1 drugs and “the development of specific psychiatric AEs.” Chen et al's list included “eight categories of psychiatric AEs, namely, nervousness, stress, eating disorder, fear of injection, sleep disorder due to general medical condition—insomnia type, binge eating, fear of eating, and self-induced vomiting.” The study even provided a median time to onset, which was 31 days (although it varied across the drugs)—suggesting that, among those people who reported negative psychological outcomes, most experienced their symptoms about a month after first taking the drugs. Later studies found even more serious effects. In the journal Nature, Kornelius et al. published a paper in 2024 identifying a “significant association between GLP-1…treatment and [a] 98% increased risk of any psychiatric disorders. Notably, patients on GLP-1 RAs exhibited a 195% higher risk of major depression, a 108% increased risk for anxiety, and a 106% elevated risk for suicidal behavior.” This study focused on psychiatric conditions in patients with obesity, and included over 162,000 patients split into matched pairs (meaning: one control subject, one experimental subject). Not all GLP-1 drugs had the same psychiatric effects: Ozempic was associated with an “approximately 2.4-fold increase in risk” of suicidal ideation, when compared to Wegovy and Saxenda. Plus, different types of patients had different drug outcomes. As Kornelius et al. (2024) wrote, “Females had a higher risk of anxiety and suicidal ideations or attempts compared to males. Younger participants (18-49 years) exhibited a higher risk of suicidal ideations or attempts, while older participants (≥ 70 years) had a lower overall risk of psychiatric diseases. Additionally, racial differences were observed, with Black patients showing a higher risk of suicidal ideations or attempts compared to White and Asian patients.” The study urged physicians to consider their patients’ psychiatric histories before prescribing drugs like Ozempic. But just as the potentially bad news about GLP-1 receptor agonists had begun to create a clear picture, other studies complicated it by finding that sometimes, these drugs can have antidepressant effects. In the American Journal of Geriatric Psychiatry, Chen, X et al (2024) write that these drugs induced “significant reductions in the depression rating scales compared to control treatments,” and were found to “alleviate depressive symptoms” in patients with Type 2 diabetes. And when using only the results of randomized controlled trials—which many people say produce the most reliable type of scientific data—GLP-1 receptor agonists showed a significant positive effect on depressive symptoms in adults. So as of now, the jury is still out, and a final understanding of the psychological effects of the current crop of weight loss drugs has not yet been achieved. Research on the risks and benefits of GLP-1s is still being conducted, and thousands of new social media comments are building up every day. Taking these drugs may well be associated with a risk of psychological harm—but even so, your physician may also be able to provide evidence of medical risks inherent in maintaining a heavier-than-average weight. In any case, all weight-related decisions are extremely personal and can be very complex; it’s unfortunate that for now, the potential risks inherent in GLP-1 use may only complicate the picture further. Note: This article originally appeared on Psychology Today .

Esketamine combined with a serotonin-norepinephrine reuptake inhibitor (SNRI) for treatment-resistant depression (TRD) was linked to significantly lower rates of several adverse outcomes than esketamine plus a selective serotonin reuptake inhibitor (SSRI), new research showed. Prior research has suggested that esketamine combined with either antidepressant is effective for TRD. But whether an add-on SNRI would yield better results than add-on SSRI was unclear due to a lack of head-to-head comparisons. The retrospective cohort study of more than 55,000 participants with TRD showed that adding an SNRI to esketamine nasal spray was associated with significantly lower rates of all-cause mortality, hospitalization, and depression relapse than using add-on SSRI. However, esketamine plus SSRI was linked to a lower incidence of suicide attempts. While both treatment combinations were linked with reduced outcomes, “notable differences exist between them,” study investigator Antonio Del Casale, MD, PhD, Sapienza University of Rome, Rome, Italy, and colleagues wrote. “These findings emphasize the critical role of selecting the appropriate antidepressant partner for esketamine and tailoring treatment to an individual patient profile,” they added. The results were published online on April 2 in JAMA Psychiatry . Lower Relapse Rate For the study, researchers assessed data collected in electronic medical records across 20 countries. They included 55,480 participants with TRD, half of whom were treated with esketamine plus an SNRI (58.6% women; mean age, 45.9 years) and the other half with esketamine plus an SSRI (57.7% women; mean age, 46 years). SNRIs used were desvenlafaxine, duloxetine, levomilnacipran, milnacipran, or venlafaxine. SSRIs used were citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, or vilazodone. Results showed that in the overall study population, relapse rates for depression (17.8%), all-cause mortality (7.2%), hospitalization (0.1%), and suicide attempts (0.4%) were low throughout the 5-year observation period. However, the group receiving esketamine plus an SNRI vs add-on SSRI had a significantly lower relapse rate (14.8% vs 21.2%; risk ratio [RR], 1.43) and lower rates of all-cause mortality (5.3% vs 9.1%; RR, 1.72) and hospitalization (0.1% vs 0.2%; RR, 3.01; all P < .001) Although low in both groups, incidence of nonfatal suicide attempts was slightly but significantly lower in the group receiving esketamine plus an SSRI (0.3% vs 0.5%, P = .04). Further survival analysis showed a 91.4% 5-year survival probability for the esketamine plus SNRI group vs 86.9% for the esketamine plus SSRI group (P < .001). “Across the study sample, esketamine combined with either an SSRI or an SNRI demonstrated consistently low risks across all outcomes,” the researchers wrote. Still, there were differences, and the study showed that “choice of antidepressant combined with esketamine can significantly impact clinical outcomes in TRD,” they added. The investigators reported no relevant financial relationships. Note: This article originally appeared on Medscape .

Rates of depression and anxiety were significantly higher in people with chronic pain than in those without pain, results of a new meta-analysis and systematic review showed. Prevalence was also higher based on pain type, with higher rates of depression and anxiety among those with fibromyalgia than those with osteoarthritis, investigators found. “The surprising finding is the significant distribution of prevalence in different pain conditions — people with certain types of pain are more vulnerable to depression and anxiety, which is important from a clinical perspective,” lead investigator Rachel Aaron, PhD, assistant professor at Johns Hopkins Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, told Medscape Medical News. The findings were published online on March 7 in the JAMA Network Open . Addressing the Gap In previous population studies, prevalence rates of co-occurring chronic pain and anxiety and depression symptoms varied widely. There was the need for a systematic review to synthesize the findings and clearly define the overall impact of chronic pain and co-occurring depression and anxiety. To address the gap, researchers reviewed 376 studies published between 2013 and 2023 with 347,468 adults with chronic pain (excluding chronic headaches) and 160,564 control participants across 50 countries. The mean age of the pain group was 51 years, and 70% were women. Overall, adults with chronic pain were at higher risk for clinical symptoms of depression and anxiety than clinical and nonclinical control individuals. Investigators recorded a pooled prevalence of 39.3% for clinical symptoms of depression (95% CI, 37.3%-41.1%) and 40.2% for clinical symptoms of anxiety (95% CI, 38%-42.4%). This was considerably higher than rates of depression (13.9%) and anxiety (16.4%) reported in the control groups. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis criteria, 37% of adults with chronic pain met diagnostic criteria for major depressive disorder compared with 10.1% in the control group. Generalized anxiety disorder was also more common in the chronic pain group vs the control group (16.7% vs 3.5%, respectively). Importance of Pain Type? Investigators also found that certain types of pain conditions were more strongly associated with depression and anxiety than others. For example, depression and anxiety were higher in people with fibromyalgia than in those with osteoarthritis (54% vs 29.1% and 55.5% vs 17.5%, respectively). “Although we were unable to test directionality of the relationship between chronic pain, depression, and anxiety in the study, one thought is people with fibromyalgia and other nociplastic-related pain conditions are more vulnerable to developing depression and anxiety in the first place, and that could be a factor driving chronic pain,” Aaron said. Prevalence of depression and anxiety was also higher in younger individuals and in women (P < .001 for both), which Aaron said, “replicates what we see in the general population that rates of depression and anxiety are higher in women.” Clinical symptoms of depression were higher among those recruited from clinical settings, while longer pain duration was associated with greater risk for anxiety symptoms . The authors reported high heterogeneity, particularly across subgroup analyses. “What that means is that we cannot say with a great deal of certainty who is more vulnerable to depression and anxiety in chronic pain and why, although we can make some broader generalizations,” Aaron explained. The findings point to the importance of routine screening of depression and anxiety in clinical settings where people with chronic pain are seen, Aaron said. Moreover, “while we highlight that depression and anxiety is high, we don’t want to forget that it is not the case for everybody,” Aaron added, noting that 60% of people with chronic pain did not meet criteria for significant levels of depression and anxiety. Directionality Problems Commenting on the study for Medscape Medical News, Gary Small, MD, chair of Psychiatry at Hackensack University Medical Center, Hackensack, New Jersey, noted that the finding that rates of depression and anxiety varied based on pain type was particularly interesting. “With arthritis, there are recognized underlying pathological processes; anxiety and depression rates were lower. But, in people with diffused pain from fibromyalgia, where you cannot locate source of pathology, depression, and anxiety rates were higher,” Small said. “This suggests a feedback mechanism between the mental experience and physical source of pain. You get anxious about your pain, and when you don’t understand where it is coming from, it makes feelings of depression and anxiety worse,” said Small, who was not involved in the study. Christina Lee, MD, psychiatrist and medical director of Mental Health Services at Kaiser Permanente in Baltimore, felt the large dataset of nearly 350,000 patients across 376 studies was both a strength and limitation. “While it provides robust evidence for the link between chronic pain and mental health, the high variability across studies makes it difficult to draw precise conclusions. Some studies used self-reported symptoms, while others relied on clinical diagnoses, leading to inconsistencies in measurement,” she said. She also noted that the actual rate of diagnosed psychiatric disorders was lower. “Are we underdiagnosing these conditions, or are symptoms fluctuating rather than meeting full clinical criteria?” she asked. “This study does not establish causation. Does chronic pain trigger depression, or do mood disorders exacerbate pain perception?” Lee said. Note: This article originally appeared on Medscape .

Girls are twice as likely as boys to be diagnosed with depression, and researchers in London have now uncovered clues as to why. Girls' brains are more likely to use a common dietary amino acid called tryptophan in a way that is neurotoxic, or harmful to nerves, even though most people's brains use it to make a compound that is neuroprotective, or helpful to nerves. Girls whose brains tended toward this neurotoxic process also were more likely to have blood test results that showed their bodies were in an inflammatory state. The girls most likely to have these processes also scored highly on a depression risk assessment or had already been diagnosed with major depression . "Depression during adolescence can significantly impact social and emotional development and increases the risk of suicide," said first author Naghmeh Nikkheslat, PhD, a senior research associate at King's College London. "Our findings offer a hopeful step toward personalized, proactive approaches that address the underlying biological factors of depression, particularly in girls." The findings build on previous evidence showing that girls are more at risk of getting depression, highlighting the need for targeted prevention and treatment. An estimated 53% of teen girls reported persistent feelings of sadness or hopelessness, compared to 28% of boys, according to a 2024 CDC report. Girls were also more likely to have suicidal thoughts and behaviors. The new study, which included 75 girls and 75 boys all around the age of 15 who lived in Brazil, showed that girls with depression, or at high risk of it, were more likely to have lower neuroprotective compound levels, compared to girls at low risk of depression . The differences were not seen among boys. The route these compounds take in the brain – either neuroprotective or neurotoxic – is called the kynurenine pathway. "Our study suggests that targeting the kynurenine pathway may offer a personalized treatment avenue for female adolescents with depression," said Nikkheslat. "By reducing inflammation or encouraging the pathway to produce more neuroprotective rather than neurotoxic metabolites, we may prevent depression from developing or becoming chronic." The researchers also found that high neurotoxic compound levels three years later were linked to an increased likelihood of persistent depression, while those whose levels had fallen were more likely to have recovered. This suggests that the neurotoxic activity makes depression harder to overcome, said Nikkheslat, who is an expert in the field of psychoneuroimmunology (the study of how the mind affects health and risk of disease). Researchers are still working to understand why these chemical differences exist between boys and girls. But "we know that increased inflammation can potentially affect the levels of these chemicals," Nikkheslat said. Childhood trauma or sexual hormones can impact inflammation, so it's possible one or the other (or both) "could contribute to these chemical abnormalities in girls." Potential treatments to be evaluated may include anti-inflammatory medications to see if their use helps push the brain away from using the neurotoxic pathway, Nikkheslat said. Stress management, exercise, and dietary interventions known to reduce inflammation should also be considered. Tryptophan – the amino acid at the center of this research – is in many common foods like poultry, dairy, seeds, and nuts, and the body uses it for many essential processes like supporting infant growth, and in making melatonin and serotonin, the latter of which is important in regulating appetite and mood. Dietary approaches and the use of or development of medications that can impact how the brain ultimately uses the byproducts of tryptophan warrant exploration as possible treatments, Nikkheslat said, noting that it also could be lifesaving to identify girls at highest risk before they develop depression. Note: This article originally appeared on Medscape .

AFFIRMING PSYCHIATRY In the early morning hours of December 4, 2024, United Healthcare CEO Brian Thompson was gunned down on the streets of New York. Although the motives of the murderer are not certain, there are indications that he carried out a vigilante-style execution as an act of terror against the insurance company itself. Unsurprisingly, his death sparked a national outpouring of opinions on the subject of health insurance and health care generally. Much of that opinion was unsparing. Rather than sympathy toward Thompson or United, most immediate social media responses ranged from ironic jokes about denied coverage to outright celebration. The schadenfreude and public rage both continued as United Group’s CEO (Andrew Witty) took to the editorial pages of The New York Times to defend his own. “Healthcare,” he opined, “is both intensely personal and very complicated, and the reasons behind coverage decisions are not well understood. We share some of the responsibility for that.” Readers do not appear to have been convinced. They called the essay “sanctimonious” and “self-serving.” “More gaslighting from an industry that has zero need to exist except to siphon profits from a non-discretionary sector,” said commentator “J M” to the tune of 4488 recommends. While I personally do not agree with Witty’s opinion, I do have to admire his courage in speaking out just days after the assassination. And I can respect the courage of other commentators who went on record to speak up for insurance companies, paddling against the riptide of public emotion that was churning forth. For instance, the editorial board of the Wall Street Journal was sympathetic to insurance companies’ efforts to “control costs,” blaming government for “policies that distort the markets and force rationed care.” Matthew Yglesias, a nationally prominent blogger, has long maintained that the major problem with America’s health care system is that providers charge too much. Economist and blogger Noah Smith has been even more forthright: I think the outpouring of schadenfreude at Thompson’s killing reflects some deep-seated popular misconceptions about the US health care industry. A whole lot of people—maybe most people—seem to regard health insurance companies as the main villains in the system, when in fact they’re only a very minor source of the problems. The insurance companies are simply hired to play the bad guy—and they’re paid a relatively modest fee for that service. Who is the real “bad guy” in our health care system? Well doctors and nurses, of course! Sure, doctors and nurses take good care of patients during the treatment process, but yet they charge “excessive prices.” According to Smith, doctors and nurses know that insurance is not going to pay a lot of those costs. The “smiling doctor” and the “gentle nurse” know full well that insurance is going to fight expensive procedures and drugs, and yet they never mention it. They offer all sorts of treatments knowing and apparently not caring that patients will get stuck with the bill. It is the providers that are the problem, you see. Insurance companies are just the poorly paid fall guy who cut costs so that doctors, nurses, and hospitals can play the ‘good guy.’ Rage Against the Insurance Companies Not surprisingly, I as a physician have a different idea about all this. My idea is that the costs of treatment are only a secondary factor in the titanic rage against the insurance companies. I truly believe that while the expense of medical care is a serious problem for our system, the rage has to do with something else: The experience of being repeatedly and systematically hoodwinked. Hoodwinked? Exactly, at least according to 1 definition of the word: “To conceal one’s true motives from, especially by elaborately feigning good intentions so as to gain an end.” That is a precise description of what many of us experience with insurance companies. We feel repeatedly deceived by protestations of the best intentions followed by cold, calculating, and duplicitous treatment. And that is why so many New York Times readers responded so negatively to Witty’s bland pronouncements of goodwill on behalf of the insurance industry. Although I have no hard evidence for this idea, I do have 20 years of experience with it in private practice. Whenever I treated individuals who paid for treatment directly out of pocket, I noticed the same pattern: They did not like the high price of treatment, but handled it calmly and kindly as long as they knew the costs in advance and could plan for them. On the other hand, individuals became absolutely livid if they had any sense of being deceived about the nature of our arrangement. For instance, people who felt deceived about being charged for no-shows, or ill-informed about whether I was an in-network provider, would turn against me instantly and literally curse me to my face. Whenever individuals did not clearly understand the deal in advance, whenever they felt ambushed by hidden costs after committing themselves to treatment, learning of some new loophole or obligatory expense felt like a stab in the back. I have never seen anyone take kindly to a stab in the back. And so, I submit that the rage against the insurance companies comes from a sense of being duped, not simply from high costs or limits of coverage. It is not the fact that insurance does not cover everything that makes people so angry. It is the impression that they pretend to cover so much, take your money for years in the form of high monthly premiums, and then in your hour of desperation and need, they refuse to pay up. Instead, they seem to find loopholes, make excuses, refuse to help, hide behind rules that no one can understand, and make it excessively difficult even to get a person on the telephone who can address the situation. It is not that insurance seems costly. It is that insurance seems duplicitous. What We Want From Insurance What do we want from insurance companies? We simply want a fair deal, a deal that we can understand in advance, a deal that they will faithfully honor. What we want is an end to the befuddling obfuscation of a secret system that resembles Kafka’s The Trial more than something designed to facilitate health care. What we want is an end to insurance feeling like a lotto card as you scratch off the next panel desperately hoping to win some actual coverage when you get sick. What we want is an end to the infuriating game of ‘heads I win, tails you lose’ routinely played in the insurance business. What we want is a straightforward transaction, not bland promises of ‘your health is in good hands with us,’ followed by callous disregard of our well-being. What we want is an end to the systematic use of delays, knee-jerk denials, inefficiencies, time-wasting, and double-talk to numb us into passive acceptance of such ethical criminality. Dearest Insurance Companies: Just offer us a deal that is straightforward and transparent, and live up to that deal. Then we can all decide if it is worth the cost, rather than going into apoplectic rage the next time that you manipulate the system against us—the very system that you design, administrate, and change at will. And then, perhaps, all the rest of us might really feel that we are on the same side, all trying our best to balance cost vs care, all trying to make the best of a very difficult situation. And then no one will have to be the “bad guy” in health care anymore. Note: This article originally appeared on Psychiatric Times .

TOPLINE: Walking 7000 or more steps per day is associated with fewer depressive symptoms and a 31% lower risk for depression than taking fewer steps, a new meta-analysis shows. METHODOLOGY: Researchers conducted a systematic review and meta-analysis of 33 observational studies that included more than 96,000 adults aged 18-91 years. Data were obtained from 27 cross-sectional and 6 longitudinal studies and from 5 major databases through May 2024. Objectively measured daily step counts and depression data were collected via various assessment tools. TAKEAWAY: The number of daily steps had a significant inverse correlation with depressive symptoms in both cross-sectional (correlation coefficient [r], −0.12; 95% CI, −0.20 to −0.04) and panel studies (r, −0.17; 95% CI, −0.28 to −0.04). Participants achieving 7000 steps per day or more showed a lower risk for depression than those achieving less than 7000 steps per day (risk ratio [RR], 0.69; 95% CI, 0.62-0.77). An additional increase of 1000 steps per day was associated with a 9% lower risk for depression (RR, 0.91; 95% CI, 0.87-0.94). Cross-sectional analysis showed that, compared with walking less than 5000 steps per day, walking 5000-7499 steps per day, 7500-9999 steps per day, and at least 10,000 steps per day were all significantly associated with fewer depressive symptoms (standardized mean difference, −0.17, −0.27, and −0.26, respectively). IN PRACTICE: "The objective measurement of daily steps may represent an inclusive and comprehensive approach to public health that has the potential to prevent depression. Small amounts of PA [physical activity] may be particularly relevant for specific populations, such as older adults and individuals with limited activities of daily living, for whom daily steps emerge as an accessible PA strategy," the investigators wrote. SOURCE: The study was led by Bruno Bizzozero-Peroni, PhD, Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain. It was published online December 16 in JAMA Network Open . LIMITATIONS: Reverse associations were possible, and causal inferences could not be made from the findings. In addition, the analysis showed substantial between-study heterogeneity in some pooled estimates, partially explained by differences in participant characteristics and step-counting devices. Most studies also lacked robust methods, potentially affecting result reliability, and the meta-analysis comparing high vs low daily step counts may have been susceptible to publication bias. DISCLOSURES: The study was funded by the University of Castilla-La Mancha, National Agency for Research and Innovation, Ministry of Economy and Competitiveness of Spain, Carlos III Health Institute, European Regional Development Fund, and European Union's Next Generation EU initiative. No conflicts of interest were reported. Note: This article originally appeared on Medscape .

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 .

COMMENTARY For those of us who grew up in Chicago, as I did, it was virtually impossible to ignore University of Chicago’s Orthogenic School. The school ostensibly treated youths with autism spectrum disorder (ASD) . At the time, autism was blamed on “refrigerator mothers,” a term coined by Bruno Bettelheim, PhD, a psychology professor and an administrator at the school. Related psychoanalytically inspired theories also loomed large in the 1950s and 1960s, which were the heydays of psychoanalysis. A European emigree who escaped the Reich, Bettelheim was a larger-than-life figure, even though his credentials later came under fire. In contrast, his book about the psychological underpinnings of fairy tales, The Uses of Enchantment (1973), retains its cache to this day. Much like the “disappeared” from Argentina’s “Dirty War,” or like fictional serial killers’ victims on Netflix, it sometimes seemed as if everyone had a friend of a friend or knew of a neighbor’s family member who had been carted off to this once prestigious but subsequently disgraced school. The school’s staff—and Bettelheim himself—would later stand accused of physically mistreating those youthful charges, not to mention psychologically damaging their maligned mothers. Even the diagnoses of ASD that supposedly “qualified” students for admission to the school would be called into question. Bettelheim eventually died by suicide. Bettelheim did indeed have a PhD in aesthetics, which probably contributed to the quality of his well-received book about fairy tales. But he represented himself as a psychologist, even though his European diploma could not be found. He claimed that it was misplaced during the war years. In contrast, it was confirmed that he trained as a psychoanalyst in Europe, where prior training in psychiatry, neurology, or psychology was not required, as it once was in the US. There is much to be said about Bettelheim that is beyond our scope here but suffice it to say that what he lacked in credentials, he compensated for with chutzpah. He was lauded for his 3 weeks’ worth of “research” (conducted without experimental design) on children reared by Israeli collectives or kibbutzim.2 That study became Children of the Dream (1967). Previously, Bettelheim chronicled his own concentration camp experiences in a widely cited 1943 paper on “Individual and Mass Behavior in Extreme Situations.” That study made him a de facto spokesperson about the stresses of concentration camps—yet it was later learned that he himself had never been incarcerated in a camp, as he had claimed. Most importantly, Bettelheim promoted since-debunked and much-maligned—yet highly persuasive—theories about “refrigerator mothers” who allegedly caused their children’s autism. His best-selling book, The Empty Fortress: Infantile Autism and the Birth of the Self (1967), established him as an expert in the field and attracted the not-always-favorable attention of well—respected reviewers, such as Stella Chess, MD, in JAMA, and elsewhere. Many medical journals subsequently denounced his studies on autism. Scientific research has since linked up to 80% of ASD cases to genetic factors (with some inherited from parents, but probably more from accidental chromosomal breakage or spontaneous mutations). Some 200 to 1000 genes contribute to ASD risks . Moving forward to the present day: knowing about this background—and remembering my “disappeared” neighbor—I would come to feel especially saddened whenever I encountered parents of children on the spectrum who could not shake the lingering shadows left by these unfounded accusations made decades earlier. As recompense, I could console them with current scientific data that contradicts Bettelheim’s theory, or I could direct them to high quality informational programs on ASD, like the ones hosted by Mount Sinai’s Seaver Center, which is affiliated the same medical school where I serve as voluntary faculty. . . or I could take an entirely different approach and alert them to the success of IDF’s Unit 9900. This unique unit is comprised of young adults who are on the spectrum and who are recruited because they can hyperfocus for hours on end and can attend to details that escape the attention of neurotypical soldiers. These volunteer recruits are noncombatants who work on computer screens and take part in an aptly named program, Spectrum of Talent. My goal was not to goad anyone to enlist their children in Israel’s IDF, not by a longshot, given that we in psychiatry are mandated to maintain strict boundaries about separating our own political or philosophical or religious persuasions from our patients’ belief systems. Rather, my intent was to reassure distressed families that their children with ASD could possess untapped abilities that are deemed valuable enough to merit a special program. More about Unit 9900, which is referred to as “Roim Rachok” (translated as “we see far”) and which was the progenitor of related and expanded programs in IDF, and which has been written about extensively in Times of Israel articles,5-8 as well as by American business publications. Articles on the topic appear in men’s magazines such as Esquire or in The Atlantic, a more generic literary monthly. Hadassah Magazine, published by a Jewish women’s organization, also weighs in on “An IDF Program for Teens on the Autism Spectrum.” The mere fact that this unique unit was the brainchild of unrelated parents of adolescents with ASD is especially compelling, for it confirms that families can advocate for their children, to help them achieve more than had previously been expected of them and to help these young adults integrate into society at large and shed their outsider status. Even though persons with ASD can be exempted from Israel’s military obligations, the participants in this pilot program volunteer on their own accord. Many elect to remain after completing their terms of service. Qualified volunteers are routed to professional training programs that tap into their innate skills, skills which confer a comparative advantage over neurotypical individuals. By their own admission, these young adults with autism focus on details for extended periods of time and relish repetitive tasks rather than resenting them. Many like lists of tasks. The first graduates learned to analyze aerial and satellite photographs. The expanded program trains participants for software quality assurance, information sorting, electro-optics, and electronics. A key 9900 task is to screen vast numbers of photos of the same subject matter in order to detect small variations between them. Sometimes they scour social media for emerging trends. Apart from their technological know-how, many participants possess specialized knowledge on topics ranging from archaeology, languages, or music. When enlisted, these special soldiers are accompanied by therapists and psychologists who help them navigate potentially stress-inducing social barriers that they face. About 90% finish their program, prepared for future careers in technological fields should they decide to leave the IDF. As testimony to the success of this pilot program, military divisions in the UK, US, and Singapore expressed interest in developing the model on their own shores. How uplifting this information can be, especially for families of children who might have been marginalized and undermined. Note: This article originally appeared on Psychiatric Times .