Depression and anxiety are among the most common complications of stroke, affecting 1 in 3 and about 1 in 4 survivors, respectively. These disorders are associated with higher mortality rates, often obscuring the path to recovery. The American Heart Association (AHA)/American Stroke Association (ASA) last published its scientific statement on poststroke depression (PSD) in 2016. Although this statement doesn’t cover poststroke anxiety (PSA), the 2019 Canadian Stroke Best Practices update recommends screening for PSA and apathy, which often coexist in the absence of PSD. It advises management with pharmacotherapy, psychotherapy, or nonpharmacologic interventions such as exercise or music therapy, while noting there is limited evidence for the use of psychostimulants. New research on the most effective treatments for depression and the lack of information on anxiety after stroke have prompted some neurologists to ask: Is it time for new guidance? What’s the Prevalence, Who’s at Risk? Recent data from the South London Stroke Register Study, which followed 2295 patients with PSD for 18 years, revealed that 33% of those with stroke experienced PSD in the first 3 months following the event, 55% within a year, and 88% within 5 years. The study’s investigators noted that individuals with PSD were at substantial risk for persistent depression within a year and recommended PSD screening in all patients within the first 3-6 months following stroke. “The course of PSD is dynamic,” Nada El Husseini, MD, director of the Stroke Research Fellowship Program at Duke University Medical Center, Durham, North Carolina, and a co-author of the AHA/ASA 2016 statement on PSD, told Medscape Medical News. Some people experience depression soon after a stroke and recover within a year, whereas others develop PSD a year after stroke, she noted. Risk factors for PSD in the first 3 months following stroke include previous mental illness, a family history of mental illness, female gender, being younger than 70, and stroke severity. A recent analysis in the Journal of Affective Disorders examined three cohorts from STROKOG (The Stroke and Cognition Consortium), revealing a PSA prevalence of 35%. Investigators found risk factors for PSA included female gender, co-occurrence of PSD, and poststroke cognitive impairment. Most cases of PSA surface within the first year after stroke. Phobia and generalized anxiety disorder were the most common anxiety subtypes. In addition to screening, early and aggressive intervention for PSD is necessary, Bruce Ovbiagele, MD, vice chair of the committee that developed the statement, told Medscape Medical News. “With stroke, we speak about the three dreaded Ds: death, dementia, and disability. But there is a fourth, and that is depression, and it is not addressed to the degree it should be,” said Ovbiagele, professor of neurology, health policy, and global health at the University of California, San Francisco. PSD is underdiagnosed and undertreated, he added. The same appears to be true for PSA, the authors of a commentary published in October in Stroke wrote. “While awareness of PSA has increased in recent years, research into the identification and treatment of PSA continues to receive less attention than poststroke depressive disorders,” they added. “With similar prevalence rates between PSA and poststroke depression, an increased understanding of the diagnosis and treatment of PSA disorders is needed.” What Causes PSD and PSA? Although psychosocial factors can contribute to the development of depression or anxiety after a stroke, research suggests that neurologic damage caused by the stroke itself plays a significant role. A 2023 literature review examining the potential mechanisms underlying PSD showed stroke in regions such as the prefrontal cortex, limbic area, and basal ganglia can disrupt key pathways of mood-related neurotransmitters, potentially leading to depressive disorders. The review also cited numerous studies linking PSD to neuroinflammation. Some experts theorize that inflammation from stroke causes the release of pro-inflammatory cytokines, which can lead to decreased serotonin. Serotonin deficiency is believed to play a significant role in the development of depressive symptoms. Another 2023 study revealed that more than 80% of immune proteins associated with mood were elevated among individuals with PSD, suggesting a link between an overactive immune system and the disorder. These investigators also found that several pro-inflammatory cytokines, such as interleukin-6, were associated with PSD. Experts believe that such biomarkers can be used to guide treatment. Depression and anxiety after stroke often co-occur alongside cognitive impairment, physical disability, and neurologic damage, making the conditions more challenging to treat than depression or anxiety in the general population, Ovbiagele noted. Effective treatment may require a multidisciplinary approach, he added. For instance, if depressive symptoms appear at any point as a stroke patient transitions from the acute setting to rehabilitation to primary care, there must be clear communication between the patient’s treatment team about treatment strategies. Ongoing treatment may involve a psychiatric consult and psychotherapy, he said, and all clinicians should remain informed about the treatment plan. As reported previously by Medscape Medical News, there are a few theories about what distinguishes PSD from nonstroke depression. A 2023 meta-analysis showed greater severity and prevalence of emotional dysregulation and less anhedonia in people with PSD compared with their counterparts with depression and no stroke history. People with PSD were more likely to have cognitive impairment and difficulty controlling muscle contractions, which is not uncommon after stroke. Unlike major depression, PSD is linked to the ischemic event, a 2018 review suggests. In particular, the size and number of ischemic lesions, and whether the lesions disrupt the midbrain, limbic, and medial prefrontal cortical circuitry, are implicated in depression. “In particular, white matter lesions are associated with metabolic alterations in this circuitry and are correlated with major depression,” the article states. What Works for PSD? As the authors of the 2016 AHA/ASA statement noted, there are few large studies to help guide clinical management of PSD. However, some evidence suggests that escitalopram and sertraline may be effective treatment options. A 2022 meta-analysis of seven randomized controlled trials showed a standardized mean difference of -1.25 on Hamilton Depression Scale (HAM-D) scores (P < .001) among participants allocated to escitalopram vs placebo. A 2024 study added to those findings. The randomized controlled trial of 60 stroke patients showed that treatment with sertraline (100 mg) or escitalopram (20 mg) was associated with a statistically significant decrease in HAM-D scores (P < .05) after 8 weeks of treatment. Data on fluoxetine are mixed. As previously reported by Medscape Medical News , the 2021 AFFINITY trial showed that 20 mg of fluoxetine for 26 weeks did not prevent or alleviate PSD. However, a post hoc analysis of the EFFECTS trial published in 2022 showed that stroke patients reported lower depression scores after receiving 20 mg daily for 6 months. There has also been some debate over whether the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) might be linked to an increased risk for bleeding in stroke patients. A study published about a decade ago showed that SSRI users experienced a higher risk for overall major bleeding that contributed to mortality rates. A subsequent study, also covered by Medscape Medical News, revealed that SSRI use in patients with intracerebral hemorrhage increased the risk for recurrence. However, other research showed no such increased risk. But new data appear to put this controversy to rest. In an analysis presented at the 2024 AHA annual meeting, researchers examined the health records of more than 650,000 stroke patients, comparing the bleeding risk among those taking SSRIs/SNRIs vs that in patients who took other antidepressants or none at all. Early use of SSRIs or SNRIs during the subacute recovery phase of acute ischemic stroke was not associated with increased bleeding risk in most patients, although a 29% higher risk for hemorrhagic stroke was observed in those who took antidepressants while also on dual antiplatelet therapy. Bleeding risk was also 15% higher with the use of other antidepressants compared with SSRIs or SNRIs. “Our findings should reassure clinicians that for most stroke survivors, it is safe to prescribe SSRI and/or SNRI antidepressants early after stroke to treat post-stroke depression and anxiety, which may help optimize their patients’ recovery,” lead investigator Kent Simmonds, DO, PhD, UT Southwestern Medical Center, Dallas, Texas, said in a press release. What Works for PSA? If research on PSD is lacking, data on the most effective treatments for PSA are even more scarce. In fact, authors of a 2021 narrative review published in Stroke found only three small trials on treatments for PSA. One study compared paroxetine or paroxetine plus psychotherapy vs standard care. Another examined buspirone hydrochloride vs standard care. The third study included data on a relaxation compact disc vs a waitlist control. Reviewers said the studies were sufficient to guide clinical practice, citing a high risk of methodological bias in all three. A fourth study, on the feasibility of a guided self-help cognitive-behavioral therapy (CBT) program delivered online and over the phone, was inconclusive. “Thus, large-scale, adequately powered, well-designed trials are needed to evaluate interventions to treat poststroke anxiety,” the authors wrote. In the absence of more defined recommendations, recent data suggest that more clinicians may be turning to benzodiazepines, often prescribing far more than the American Geriatrics Society advises. Use of these drugs in adults older than 65 years is associated with higher risk for cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. In addition, some research shows that benzodiazepine use is associated with increased poststroke mortality at 90 days. Despite these warnings, investigators at Massachusetts General Hospital in Boston recently reported that nearly 5% of Medicare patients with acute ischemic stroke received a prescription for benzodiazepines within 90 days of discharge. Of these patients, 55% were prescribed benzodiazepines for durations ranging from 15 to 30 days. Guidance from the World Health Organization suggests that benzodiazepines should be prescribed for no more than 7 days. In an editorial accompanying this study, Justin J. MacKenzie, PhD, and Veronica Moreno-Gomez, MD, said the findings highlight “a concerning pattern of possible BZD [benzodiazepine] overprescription in vulnerable adults following ischemic stroke.” Some evidence suggests that various nonpharmacologic treatments are effective for PSA and PSD. A 2021 meta-analysis of 10 studies showed CBT was associated with improvement in PSD and PSA symptoms and that the benefits persisted up to 3 months after treatment. Other studies suggest potential benefits from exercise, acupuncture, and neuromodulation, although many of these trials were small or yielded inconsistent results. Time for New Guidance? Updated guidance for managing PSD and PSA would enable physicians to screen stroke patients more effectively for symptoms, Moreno-Gomez, who is an associate professor of neurology at the University of Utah in Salt Lake City, told Medscape Medical News. Any new guidance should identify the most effective and safest pharmacologic and nonpharmacologic treatments, she added. “While there is still room for improvement, the development of standardized guidelines for the short- and long-term management of anxiety will help minimize the misuse of benzodiazepines and their associated risks,” Moreno-Gomez said. The majority of studies published since the release of the statement are meta-analyses of randomized clinical trials (RCTs) with small numbers, of short duration, or with problematic diagnostic approaches, Ovbiagele said. As a result, the AHA/ASA currently has no plans to update its 2016 statement on PSD. “What we really need is a large, multidisciplinary RCT headed by neurologists, psychiatrists, and perhaps primary care physicians — all of whom play a role in the diagnosis and treatment of patients with PSD,” Ovbiagele said. The results of such large-scale research would provide a solid foundation for developing new guidance on the screening, treatment and management of PSD and PSA, he added. Amytis Towfighi, MD, chair of the AHA/ASA panel that developed the 2016 statement, told Medscape Medical News that although she could not comment on the need for updated guidance, she agreed there is a need for PSD and PSA screening. She also noted that repeated screening might be necessary because the timeline of PSD is unclear. Towfighi, chief of neurology at Los Angeles General Hospital and professor of neurology at the University of Southern California, agreed with Ovbiagele that more large-scale studies are needed to identify the most effective therapies. She highlighted the importance of including research on nonpharmacologic strategies such as music therapy, mindfulness, deep breathing, meditation, visualization, physical activity, motivational interviewing, acupuncture, and herbal remedies. Note: This article originally appeared on Medscape .

Anxiety is a normal reaction to stress. Mild levels of anxiety can be beneficial in some situations. It can alert us to dangers and help us prepare and pay attention. Anxiety disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety. Anxiety disorders are the most common of mental disorders. They affect nearly 30% of adults at some point in their lives. However, anxiety disorders are treatable with a number of psycho-therapeutic treatments (psychodynamic therapy, CBT, etc). Treatment helps most people lead normal productive lives. Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior. Fear is an emotional response to an immediate threat and is more associated with a fight or flight reaction – either staying to fight or leaving to escape danger. Anxiety disorders can cause people to try to avoid situations that trigger or worsen their symptoms. Job performance, schoolwork and personal relationships can be affected. In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must: Be out of proportion to the situation or be age-inappropriate Hinder their ability to function normally There are several types of anxiety disorders: generalized anxiety disorder, panic disorder with or without agoraphobia, specific phobias, agoraphobia, social anxiety disorder, separation anxiety disorder and selective mutism. How Common Are Anxiety Disorders? In any given year the estimated percent of U.S. adults with various anxiety disorders are listed below: Types of Anxiety Prevalence Specific Phobia 8% - 12% (U.S.) Social Anxiety Disorder 7% (U.S.) ​ Panic Disorder ​2% - 3% (U.S.) Agoraphobia 1-1.7% (adolescents and adults; worldwide) Generalized Anxiety Disorder 0.9% (adolescents)' 2.9% (adults) Separation Anxiety Disorder 4% (children); 1.6% (adolescents); 0.9%-1.9% (adults) Selective mutism ​0.03-1.9% (U.S., Europe, Israel) Women are more likely than men to experience anxiety disorders. Types of Anxiety Disorders Generalized Anxiety Disorder Generalized anxiety disorder involves persistent and excessive worry that interferes with daily activities. This ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping. Often the worries focus on everyday things such as job responsibilities, family health or minor matters such as chores, car repairs, or appointments. Panic Disorder The core symptom of panic disorder is recurrent panic attacks, an overwhelming combination of physical and psychological distress. During an attack, several of these symptoms occur in combination: Palpitations, pounding heart or rapid heart rate Sweating Trembling or shaking Feeling of shortness of breath or smothering sensations Chest pain Feeling dizzy, light-headed or faint Feeling of choking Numbness or tingling Chills or hot flashes Nausea or abdominal pains Feeling detached Fear of losing control Fear of dying Because the symptoms can be quite severe, some people who experience a panic attack may believe they are having a heart attack, fear of dying, or some other life-threatening illness. They may go to a hospital emergency department. Panic attacks may be expected, such as a response to a feared object, or unexpected, apparently occurring for no reason. A panic attack can occcur in the content of any anxiety disorder, however panic disorder is a recurrent, uncontrollable condition.The mean age for onset of panic disorder is 20-24. Panic attacks may occur with other mental disorders such as depression or PTSD. Phobias, Specific Phobia A specific phobia is excessive and persistent fear of a specific object, situation or activity that is generally not harmful. Patients know their fear is excessive , but they can't overcome it, though they can rationale understand this. These fears cause such distress that some people go to extreme lengths to avoid what they fear. Examples are public speaking, fear of flying or fear of spiders. Agoraphobia Agoraphobia is the fear of being in situations where escape may be difficult or embarrassing, or help might not be available in the event of panic symptoms. The fear is out of proportion to the actual situation and lasts generally six months or more and causes problems in functioning. A person with agoraphobia experiences this fear in two or more of the following situations: Using public transportation Being in open spaces Being in enclosed places Standing in line or being in a crowd Being outside the home alone The individual actively avoids the situation, requires a companion or endures with intense fear or anxiety. Untreated agoraphobia can become so serious that a person may be unable to leave the house. A person can only be diagnosed with agoraphobia if the fear is intensely upsetting, or if it significantly interferes with normal daily activities. Social Anxiety Disorder (previously called social phobia) A person with social anxiety disorder has significant anxiety and discomfort about being embarrassed, humiliated, rejected or looked down on in social interactions. People with this disorder will try to avoid the situation or endure it with great anxiety. Common examples are extreme fear of public speaking, meeting new people or eating/drinking in public. The fear or anxiety causes problems with daily functioning and lasts at least six months. Separation Anxiety Disorder A person with separation anxiety disorder is excessively fearful or anxious about separation from those with whom he or she is attached. The feeling is beyond what is appropriate for the person's age, persists (at least four weeks in children and six months in adults) and causes problems functioning. A person with separation anxiety disorder may be persistently worried about losing the person closest to him or her, may be reluctant or refuse to go out or sleep away from home or without that person, or may experience nightmares about separation. Physical symptoms of distress often develop in childhood, but symptoms can carry though adulthood. Selective Mutism Children with selective mutism do not speak in some social situations where they are expected to speak, such as school, even though they speak in other situations. They will speak in their home around immediate family members, but often will not speak even in front of others, such as close friends or grandparents. The lack of speech may interfere with social communication, although children with this disorder sometimes use non-spoken or nonverbal means (e.g., grunting, pointing, writing). The lack of speech can also have significant consequences in school, leading to academic problems and social isolation. Many children with selective mutism also experience excessive shyness, fear of social embarrassment and high social anxiety. However, they typically have normal language skills. Selective mutism usually begins before age 5, but it may not be formally identified until the child enters school. Many children will outgrow selective mutism. For children who also have social anxiety disorder, selective mutism may disappear, but symptoms of social anxiety disorder may remain. Risk Factors The causes of anxiety disorders are currently unknown but likely involve a combination of factors including genetic, environmental, psychological and developmental. Anxiety disorders can run in families, suggesting that a combination of genes and environmental stresses can produce the disorders. Diagnosis and Treatment The first step is to see your doctor to make sure there is no physical problem causing the symptoms. If an anxiety disorder is diagnosed, a mental health professional can work with you on finding the best treatment. Unfortunately, many people with anxiety disorders don't seek help. They don't realize that they have a condition for which there are effective treatments. Although each anxiety disorder has unique characteristics, most respond well to two types of treatment: psychotherapy or "talk therapy," and medications. These treatments can be given alone or in combination. Cognitive behavior therapy (CBT), a type of talk therapy, can help a person learn a different way of thinking, reacting and behaving to help feel less anxious. Medications will not cure anxiety disorders, but can provide significant relief from symptoms. The most commonly used medications are anti-anxiety medications (generally prescribed only for a short period of time) and antidepressants. Beta-blockers, used for heart conditions, are sometimes used to control physical symptoms of anxiety. Self-Help, Coping, and Managing There are a number of things people do to help cope with symptoms of anxiety disorders and make treatment more effective. Stress management techniques and meditation can be helpful. Support groups (in-person or online) can provide an opportunity to share experiences and coping strategies. Learning more about the specifics of a disorder and helping family and friends to understand the condition better can also be helpful. Avoid caffeine, which can worsen symptoms, and check with your doctor about any medications. Related Conditions Post-traumatic stress disorder (PTSD) Acute stress disorder Obsessive-compulsive disorder Adjustment disorder

What current events are keeping Americans up at night? The economy, gun violence, and hate crimes top the list, results from a newly released American Psychiatric Association (APA) survey showed. Anxiety about international conflicts — namely, the Russia-Ukraine and Israel-Hamas wars — also remains high. “While we like to stay informed, the news can also impact our mental health, and being mindful of that impact is important. If current events seem overwhelming it may be time to limit your news consumption,” APA CEO and Medical Director Marketa M. Wills, MD, MBD, said in a statement. Survey results also revealed the election and the holidays were common sources of stress. “Election stress is common, and it’s important to recognize that, as we’re spending more time with family around the holidays, we might need to have a strategy to manage our own mental health during these times,” Howard Liu, MD, MBA, chair of the Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska, told Medscape Medical News. “As with any difficult topic, we all have different levels of avoidance or desire to engage, and it’s okay to set boundaries based on past conversations with family. I think sometimes we get drawn into arguments that we don’t want to have or may not be productive for either side,” said Liu, who chairs the APA Council on Communications. In line with trends throughout 2024, adults polled by the APA in November were most anxious about the economy (75%), gun violence (64%), and hate crimes (60%). The survey included 2200 US adults as part of the APA’s Healthy Minds monthly series. Anxiety about international conflicts remained high in November at 57% — but was down from 65% in August. Election anxiety remained high in mid-November but not as high as before the election. In August, 72% of Americans said they were anxious about the 2024 election. In November, just after the election, 50% reported anxiety over the election outcome. “I think the anticipation of change can sometimes be worse than the change itself. So I think a lot of people are now taking the attitude of — let’s wait and see what actually happens,” said Liu. Half the adults (50%) anticipate the same amount of stress as the 2023 holiday season, while almost one third expect more stress (28%), and one fourth anticipate less stress (23%). When asked how the holidays generally affect their mental health, 38% said it has positive effects, and 21% said the opposite was true. Anxiety About the Future After a divisive election, most Americans are ready to avoid politics at holiday gatherings, results of a separate poll conducted by the American Psychological Association in late November showed. That poll, which included 2000 US adults, showed that more than 7 in 10 (72%) said they want to avoid talking about politics with family and friends over the holidays. In addition, nearly 2 in 5 adults (39%) reported they were stressed by the thought of politics being raised at holiday gatherings and would try to avoid family members they disagree with. Younger adults were significantly more likely than their older counterparts to report they plan to avoid family over the holidays. The future of the nation also weighs on the minds of many Americans. Another poll conducted by the American Psychological Association in August prior to the 2024 US presidential election showed that 77% of respondents said the future of the nation was a significant source of stress for them. In the postelection poll, more than one third of adults (35%) said they are more stressed about the future of the nation now than they were leading up to the election, and another third reported they are now less stressed (32%). A quarter of adults (24%) said their stress about the future of the nation was unchanged, and 9% said they were not stressed about the future of the nation then or now. “There’s still clearly a lot of uncertainty, and there’s a lot of activity right now for the president-elect,” which can contribute to anxiety, C. Vaile Wright, PhD, psychologist, researcher and spokesperson for the American Psychological Association, told Medscape Medical News . These data also show that many Americans have little or no trust in the government, with some wanting to leave the United States. “It’s a reflection of the lack of strong leadership across the board in this country. We have a governmental system in place that does not seem to serve the people, but to serve corporations and maintenance of power. I think people are disillusioned with it and that creates a lack of trust and hopelessness,” Wright noted.

Of all the currently available pharmacological and nonpharmacological therapies for attention deficit and hyperactivity disorder (ADHD) in adults, only stimulants and atomoxetine are effective at reducing core symptoms, results of a large comprehensive meta-analysis showed. The study of 113 randomized controlled trials with nearly 15,000 adults with a formal diagnosis of ADHD also revealed that atomoxetine is less acceptable to patients and that results of efficacy of nonpharmacological strategies are inconsistent. Data on long-term efficacy of ADHD therapies are lacking, investigators noted, so these results only apply to short-term efficacy. “There is a lot of controversy about medication, so these are quite reassuring data and certainly reinforces the role of medication as a treatment for ADHD,” study investigator Samuele Cortese, MD, PhD, with University of Southampton, Southampton, England, said during a press briefing hosted by the UK Science Media Center where the findings were released. The results also point to the “possible role of nonpharmacological interventions, which are currently not well established in current guidelines. However, there is a need for better evidence to fully understand the exact effect of these nonpharmacological interventions,” Cortese noted. The study was published online on December 17 in The Lancet Psychiatry . Bridging the Knowledge Gap Once thought to be a childhood disorder only, ADHD is now well-known to persist into adulthood, affecting roughly 2.5% of the general adult population worldwide. The comparative benefits and harms of available interventions for ADHD in adults remain unclear. To address this knowledge gap, researchers did a comprehensive systematic review and component network meta-analysis comparing a broad range of drug and nondrug treatments for adults with ADHD across several outcomes. For reducing core ADHD symptoms at 12 weeks, only stimulants and atomoxetine were better than placebo in self-reported and clinician-reported rating scales, the study team found. For stimulants, the standardized mean differences (SMDs) on the self-reported and clinician-reported scales were 0.39 and 0.61, respectively. The corresponding SMDs for atomoxetine were 0.38 and 0.51. There was no evidence that ADHD medications were better than placebo in improving additional relevant outcomes such as quality of life. In terms of nondrug interventions, cognitive behavioral therapy, cognitive remediation, mindfulness, psychoeducation, and transcranial direct current stimulation were better than placebo only on clinician-reported measures, with SMDs of −1.35, −0.79, −0.77, and −0.78, respectively. However, the evidence for nondrug strategies is less conclusive overall, with “discordant results across types of raters and based on a small body of evidence,” the authors wrote in their article. And evidence for long-term efficacy (beyond 12 weeks) for ADHD interventions is “limited and under-investigated,” they said. Regarding acceptability, all strategies were similar to placebo except for atomoxetine and guanfacine which had lower acceptability than placebo. “It’s very important to emphasize that we focused on the average effect, not at an individual level,” first author Edoardo Ostinelli, MD, with University of Oxford, England, said at the briefing. “Therefore, we cannot make any recommendation at an individual level. We need studies with individual participant data so that we can personalize treatment.” Cortese said the information from this analysis may be particularly important for “psychoeducation” of the patient before actually starting with a treatment plan. Patients often ask about nonpharmacological interventions and this study provides the “best synthesis of available data to inform these discussions,” he said. Experts Weigh In Several experts weighed in on the results in a statement from the UK Science Media Center. Celso Arango, MD, PhD, psychiatrist with Gregorio Marañón General University Hospital, Madrid, Spain, noted that there is a “clear shortage of research on ADHD in adulthood, particularly regarding medium-term (beyond 12 weeks) and long-term treatment outcomes. Consequently, the findings are applicable only to short-term treatment.” Another strength of the study is that it was developed with input from people with ADHD, Arango added, making it “highly relevant.” The majority of studies available for the analysis involved pharmacological treatments, which is important to consider when interpreting the findings, noted Katya Rubia, PhD, professor of cognitive neuroscience, King’s College London, London, England. “For example, for neurostimulation, only 10 studies were included and on very heterogenous stimulation methods,” Rubia said. “The evidence on the efficacy of neurostimulation is therefore hardly conclusive and more studies are needed to establish their efficacy.” Roi Cohen Kadosh, PhD, professor of cognitive neuroscience, University of Surrey, Guildford, England, agreed. While the study is a “valuable contribution to the literature,” it sheds light on “both the scarcity of neurostimulation research and the limited exploration of combined treatment approaches for ADHD,” he said. “While novel neurostimulation methods linked to neuroplasticity — such as those we have demonstrated to be superior in children with ADHD — were not covered here, they have shown promising and lasting benefits. In contrast, research in adults remains relatively underdeveloped. Moving forward, greater emphasis on innovative, tolerable, personalized, and sustainable neurostimulation approaches is essential to meet the unmet clinical needs of adults with ADHD ,” Kadosh added. Note: This article originally appeared on Medscape .

People with psychotic disorders like schizophrenia frequently experience cognitive difficulties, including problems with attention, concentration, and memory. These cognitive difficulties are often early symptoms that appear before the onset of psychosis. In a study funded by the National Institute of Mental Health, researchers identified consistent links between brain connectivity and cognitive function in people with early stage psychosis and in people at high risk who later developed psychosis. This discovery could help researchers and clinicians better understand the factors that lead to psychosis, informing earlier intervention and improved treatments. What did the researchers look at in the study? Researchers Heather Burrell Ward, M.D. (Vanderbilt University Medical Center), Roscoe Brady, Jr., M.D., Ph.D. (Beth Israel Deaconess Medical Center), Kathryn Eve Lewandowski, Ph.D. (McLean Hospital), and colleagues examined data from two large multisite studies. The studies—the Human Connectome Project for Early Psychosis (HCP-EP) and the North American Prodrome Longitudinal Study 2 (NAPLS2)—include participants with early psychosis or at high risk for psychosis, as well as healthy participants with no known risk for psychosis. The research team performed a comprehensive analysis of participants’ neural connections, or connectome, to identify robust associations between brain connectivity and attention. Attention was measured using an auditory task specifically developed to assess sustained attention in people with or at risk for psychotic disorders. The task gauges three aspects of attention: vigilance, memory, and ability to manage interference. In total, the researchers analyzed data from 96 HCP-EP participants with early psychosis and 213 NAPLS2 participants at high risk for psychosis. What did the study find? Overall, participants with psychosis or an increased risk for psychosis performed worse on the attention task than their peers who were not at risk for psychosis . Data from participants with early psychosis revealed associations between their brain connectivity and attention, in line with the researchers’ hypothesis. Specifically, lower connectivity between an area in the medial prefrontal cortex and a region in the somatomotor cortex was associated with worse performance on the attention task. The researchers found a similar connectivity-cognition association among participants who were at increased risk for—and eventually developed—psychosis. Data from the two studies showed no connectivity-cognition associations for high-risk participants who did not develop psychosis or for participants who were not at risk for psychosis. What do the results mean? These consistent links between brain connectivity and cognition point to specific brain circuits that may contribute to cognitive difficulties in people with psychotic disorders, even before psychosis develops. However, these links do not provide evidence of a causal relationship. The researchers suggest that experimental studies using noninvasive brain stimulation techniques could help determine whether changes in these brain circuits directly impact cognitive performance. If so, these circuits may serve as specific targets for therapeutic intervention. Ward, Brady, Lewandowski, and colleagues note that recruiting participants is a particular challenge in this area of research, requiring considerable time, effort, and resources. Only a small proportion of people who are at risk for psychosis ultimately develop psychosis, and at-risk participants are often hard to identify. According to the researchers, these findings underscore how valuable large multi-site studies like HCP-EP and NAPLS2 are to improving our understanding of the factors that predict and contribute to psychosis. Note: This article originally appeared on NIHM .

Key Takeaways Negative symptoms in schizophrenia, including diminished expression and apathy, are challenging to treat and often resist conventional antipsychotics targeting positive symptoms. Distinguishing primary from secondary negative symptoms is crucial, as secondary symptoms may arise from factors like medication side effects or comorbid conditions. Pharmacological treatments, such as cariprazine and clozapine, show potential but require more evidence from randomized controlled trials. Nonpharmacological interventions, including TMS and digital phenotyping, offer promising avenues for addressing negative symptoms in schizophrenia. Emerging treatments, like psychedelics, are being investigated for their potential benefits, though their use remains controversial and requires further research. Schizophrenia is a frequently chronic and disabling disorder, marked by heterogeneous positive and negative symptom constellations. While antipsychotic medications usually manage positive symptoms effectively, there are limited treatment options for negative symptoms. Despite progress in understanding schizophrenia ’s etiology, biology, and psychopharmacology, negative symptoms remain an unmet medical need. Negative symptoms pose significant challenges for individuals with schizophrenia and their caregivers. These symptoms can be described in 5 factors. These symptoms severely impair daily functioning and can be resistant to conventional antipsychotic treatments, which primarily target positive symptoms by modulating dopamine pathways in the brain. From a phenomenological point of view, negative symptoms can be described within 2 dimensions: (1) the dimension of diminished expression, comprising alogia and blunted affect; and (2) the dimension of apathy, comprising avolition, asociality, and anhedonia. These 2 distinct dimensions are thought to have different underlying neurobiological mechanisms. Distinguishing primary negative symptoms from secondary negative symptoms is therefore an essential part of the treatment approach. Primary negative symptoms are thought to be intrinsic to the underlying pathophysiology of schizophrenia, while secondary negative symptoms are thought to be related to other factors. These factors include positive symptoms, treatment adverse effects (sedation, extrapyramidal symptoms, akathisia), anxious and depressive symptoms, environmental deprivation, substance use, other comorbid psychiatric disorders, and medical comorbidities. For instance, investigators describe a complex relationship between negative symptoms and depression in schizophrenia . Indeed, affective symptoms are commonly observed in nonaffective psychosis, affecting 50% to 80% of patients at some point during their illness. Primary evidence indicates that low mood, suicidal thoughts, and pessimism are more specifically linked to depression, while alogia and blunted affect are more closely associated with negative symptoms. Nevertheless, anhedonia, anergia, and avolition may be present in both conditions. Therefore, a thorough evaluation of clinical symptoms in individuals with schizophrenia is essential to accurately identify their nature and tailor the treatment accordingly. The causes of depressive symptoms in schizophrenia are diverse, including dysphoria induced by antipsychotic medications, psychological stressors, stigma, and traumatic life events. Addressing these causes requires a combination of nonpharmacological and pharmacological approaches. In this specific case, a switch to an antipsychotic with antidepressant properties should be considered. Add-on antidepressant is another potential option, as are cognitive behavior therapy sessions. Pharmacologic Treatments Another important point is the need to avoid first-generation antipsychotics, as these dopamine antagonists present a significant risk of inducing secondary negative symptoms due to their dose-dependent adverse effects: sedation, extrapyramidal symptoms, lower motivation, and mood. Regarding second-generation or third-generation antipsychotics, there is limited evidence based on very few randomized controlled trials (RCTs). Although amisulpride selectively blocks dopamine D2 and D3 receptors, at low doses (50 to 300 mg/day) it preferentially blocks presynaptic dopamine receptors, which may enhance dopaminergic transmission in pathways associated with negative symptoms. This contrasts with higher doses, at which it blocks postsynaptic receptors to alleviate positive symptoms. Cariprazine is also promising for the treatment of predominant and persistent negative symptoms. This second-generation antipsychotic has demonstrated efficacy in reducing negative symptoms. It acts as a partial agonist at dopamine D2 and D3 receptors with a higher affinity for D3 receptors, which are believed to play a significant role in cognitive and emotional processes. Clinical trials have shown that cariprazine not only improves positive symptoms but also has a significant impact on negative symptoms. However, current evidence is limited to a few RCTs published by the same manufacturer. Clozapine is another second-generation antipsychotic. Although clozapine presents a weak affinity for D2 receptors and antagonizes D1 and D4 receptors, it is thought to regulate glutamatergic neurotransmission, which can be beneficial for negative symptoms in schizophrenia, particularly secondary negative symptoms related to treatment-resistant positive symptoms or comorbid depression. Its efficacy for primary negative symptoms is less clear, with some studies showing modest benefits. Novel mechanism-of-action (MOA) agents such as pimavanserin are emerging for treatment of both positive and negative symptoms of schizophrenia with very interesting results. Pimavanserin is a selective serotonin 5-HT2A agonist/antagonist and a 5-HT2C receptor antagonist. In a phase 2 trial, stable patients with predominant negative symptoms of schizophrenia showed a reduction in negative symptoms after treatment with pimavanserin. However, only a small effect size was found. Therefore, further investigation with optimized dosing is warranted to determine the clinical significance of this effect. Overall, for pharmacological approaches, there is a lack of high-level evidence supporting specific interventions. Further research is necessary before recommending amisulpride or cariprazine as a treatment for negative symptoms in clinical practice. Nonpharmacological Treatments Nonpharmacological treatment methods have been found to be effective in the treatment of patients with undifferentiated negative symptoms of schizophrenia. For instance, patients with negative symptoms should have access to rehabilitation interventions such as supported employment and supported housing. We present in the Figure a decision tree for current recommendations of the treatment of negative symptoms in individuals with schizophrenia. Recent advancements in medical research have introduced potential novel treatments aimed at addressing these debilitating negative symptoms, offering new hope for improving the quality of life for those affected by this condition. The add-on of psychostimulants to concurrent antipsychotics has been studied, with various RCTs with modafinil and armodafinil. However, only limited improvement for patients with predominant negative symptoms has been found to date, which precludes current recommendation in clinical practice, pending further research.ax Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain. Research has shown that TMS can be effective in reducing negative symptoms by targeting specific brain regions involved in mood and cognition. Although many RCTs have been published, there is significant heterogeneity among included patients and stimulation parameters used. Nevertheless, in expert centers, treatment with left prefrontal repetitive TMS can be considered for patients with negative symptoms that do not improve with other interventions. Original and very recent interventions are starting to be proposed to target negative symptoms in individuals with schizophrenia, such as the use of specific serotonergic psychedelics. Arnovitz et al propose 3,4-methylenedioxymethamphetamine (MDMA) as a novel therapeutic given its ability to enhance social interactions, generate empathy, and induce a state of metaplasticity in the brain. MDMA has been shown to be an effective treatment for posttraumatic stress disorder. An open-label, ascending-dose, within-subject trial of MDMA (dose, 40-120 mg) is being conducted in the US for individuals with schizophrenia presenting negative symptoms (NCT05770375). Psilocybin, a serotonergic psychedelic, also exhibits entactogenic properties and may be of interest in addressing the negative symptoms of schizophrenia . However, the psychedelic experience or “trip” associated with these substances is controversial when considering their use as potential add-on therapies as they may trigger adverse effects in individuals with schizophrenia. Moreover, most second-generation antipsychotics (eg, risperidone, olanzapine) act as “trip stoppers,” preventing patients from experiencing the psychedelic effects that might be beneficial. Furthermore, the combination of first-generation antipsychotics with psychedelics could amplify the effects of the psychedelics, increasing the risk of worsening adverse symptoms in patients.16 It remains an open question whether the psychedelic trip is necessary to achieve the antidepressant effects of these substances. Husain et al proposed an innovative double dummy trial in patients with treatment-resistant depression to try to answer to this question. However, certain antipsychotics, such as amisulpride at moderate doses (eg, 400 mg), could theoretically be used to prevent a potential increase in positive symptoms following psychedelic use while still allowing the psychedelic experience to occur. Nevertheless, switching a stable patient’s antipsychotic regimen to accommodate the potential benefits of an add-on psychedelic treatment is also a matter of debate. Finally, the assessment of negative symptoms is also evolving with promises from digital phenotyping, offering a more precise and continuous method of monitoring than traditional assessments. By leveraging data from smartphones, wearable devices, and other digital tools, digital phenotyping can capture subtle behavioral and physiological changes that may indicate the presence or severity of negative symptoms, such as social withdrawal, reduced motivation, and diminished emotional expression. This real-time, objective data can complement clinical evaluations, providing a more comprehensive understanding of a patient’s condition and enabling personalized treatment approaches. Additionally, digital phenotyping can help in early detection of symptom exacerbation, potentially leading to timely interventions that improve outcomes for individuals with schizophrenia. Concluding Thoughts In sum, negative symptoms in schizophrenia represent a significant challenge, both in terms of patient suffering and the limitations of current treatment approaches. While advancements in pharmacological and nonpharmacological treatments show promise, particularly with novel interventions like digital phenotyping,novel MOA agents, and psychedelics, much remains to be understood and validated through rigorous research. Note: This article originally appeared on Psychiatric Times .

Two treatments for children with attention-deficit hyperactivity disorder (ADHD) have been recommended by the European Medicines Agency (EMA) to receive marketing authorizations. Paxneury for ADHD Symptoms The agency's Committee for Medicinal Products for Human Use (CHMP) said it was satisfied that Paxneury (guanfacine) reduces behavioral symptoms of ADHD such as hyperactivity, impulsivity, short attention span, and distractibility. The drug contains guanfacine, a selective alpha-2A adrenergic receptor agonist. It modulates brain signaling pathways believed to contribute to ADHD symptoms. Paxneury will be available as prolonged-release tablets at strengths ranging from 1 mg to 7 mg. It contains the same active substance as Intuniv but is available at higher strengths. The EMA confirmed the drug's satisfactory quality and bioequivalence to Intuniv. The most serious side effects associated with Paxneury are hypotension, weight gain, bradycardia, and syncope. Common side effects are somnolence, headache, fatigue, abdominal pain, and sedation. Tuzulby Modified-Release Tablets The CHMP also recommended a pediatric marketing authorization for Tuzulby, a modified-release chewable tablet for ADHD symptoms . Tuzulby’s active ingredient, methylphenidate hydrochloride, inhibits dopamine reuptake without stimulating dopamine release. The EMA said that Tuzulby's benefits are comparable to that of the reference medicine Ritalin, which contains the same active substance. However, Tuzulby is available in a different formulation and strength, designed for once-daily dosing to improve attention and behavior throughout the day. Tuzulby will be available as 20 mg, 30 mg, and 40 mg tablets. Treatment must be started under the supervision of a specialist in childhood or adolescent behavioral disorders, the committee advised Marketing authorizations recommended by the EMA are subject to approval by the European Commission. Peter Russell has been a journalist for 40 years covering international news, health, medicine, and national politics on radio, TV, and online. He is based in the UK. Note: This article originally appeared on Medscape .

For the first time since 2001, the American Psychiatric Association (APA) has updated its clinical practice guideline on borderline personality disorder (BPD). The new guideline is “quite substantial and really serves as a rich textbook of the literature, about borderline personality disorder that any clinician would find very valuable,” John Oldham, MD, MS, member of the guideline writing group, told Medscape Medical News. “The overall goal is to improve the quality of care and treatment outcomes for patients with BPD,” said Oldham, distinguished emeritus professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine in Houston, Texas. The updated guideline was published online on November 1 in the American Journal of Psychiatry. It includes eight evidence-based recommendation statements covering assessment and determination of treatment plan, psychosocial interventions, and pharmacology. Recommendations denoted by the numeral 1 after the guideline statement indicates confidence that the benefits of the intervention clearly outweigh the harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Each guideline statement also has an associated rating for the strength of supporting research evidence — high, moderate, and low, denoted by the letters A, B, and C, respectively. The APA recommends (1C) that the initial assessment of a patient with possible BPD include the reason the individual is presenting for evaluation; the patient’s goals and preferences for treatment; a review of psychiatric symptoms, including core features of personality disorders and common co-occurring disorders; a psychiatric treatment history; assessment of physical health and psychosocial and cultural factors; a mental status examination; and an assessment of risk of suicide, self-injury, and aggressive behaviors, as outlined in APA Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition. The APA suggests (2C) that the initial psychiatric evaluation of a patient with BPD include a quantitative measure to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment. The guideline lists several options, including (but not limited to) the 23-item version of the Borderline Symptom List; the Borderline Evaluation of Severity Over Time; 11-item Borderline Personality Features Scale for Children; and Difficulty in Emotional Regulation Scale. The APA recommends (1C) that a patient with BPD have a documented, comprehensive, and person-centered treatment plan and be engaged in a collaborative discussion about their diagnosis and treatment, which includes psychoeducation related to the disorder. “This is a new recommendation,” Oldham told Medscape Medical News. Another new recommendation (1B) advises a structured approach to psychotherapy that has support in the literature and targets the core features of the disorder. These include dialectical behavior therapy and mentalization-based therapy along with other therapies that have demonstrated efficacy in recent studies. The APA recommends (1C) that a patient with BPD have a review of co-occurring disorders, prior psychotherapies, other nonpharmacological treatments, past medication trials, and current medications before initiating any new medication. The APA suggests (2C) that that any psychotropic medication treatment of BPD be “time-limited, aimed at addressing a specific measurable target symptom, and adjunctive to psychotherapy.” “Medication is not a primary treatment but may help diminish symptoms such as affective instability, impulsivity, or psychotic-like symptoms in individual patients, helping them to remain engaged in treatment or reducing short-term risks of self-harm,” said Oldham. The APA recommends (1C) a review and reconciliation of medications at least every 6 months to assess the effectiveness of treatment and identify medications that warrant tapering or discontinuation. An Alternative Model of Care Oldham said it’s important to note that the Alternative DSM-5 Model for Personality Disorders (AMPD) is increasingly being integrated into clinical practice with adolescents and adults. Unlike the traditional categorical system, which diagnoses personality disorders as distinct and separate conditions, the AMPD views personality disorders along a continuum of severity and impairment. The AMPD recognizes the variability and overlap in personality disorder symptoms and provides a nuanced, individualized framework for assessment and treatment planning. Oldham co-chaired the work group that developed the proposal for the alternative model. “Despite the growing recognition of the importance of the alternative model, our systematic reviews did not identify treatment studies using the alternative model that met our inclusion criteria. Therefore, it is not included in the new guideline,” he said. Development of the guideline had no commercial funding. Oldham reported no conflicts of interest with his work on the guideline. Note: This article originally appeared on Medscape .

Key points Obstructive sleep apnea (OSA) is the world’s most common sleep-related breathing disorder. Individuals with OSA are at an increased risk of anxiety, depression, and cognitive impairment. Among men in their 50s, OSA is associated with a 6-fold increase in risk of cognitive impairment. Clinicians should always inquire into patients’ sleep health to determine if OSA is contributing to symptoms. Clinical diagnostic work is very similar to detective work. During the initial evaluation of the patient, we gather evidence from signs and symptoms, inquire into potential connections that may not be obvious to the untrained eye, and then use our medical knowledge to form a hypothesis and recommend treatments. It is rare that patients’ signs and symptoms perfectly match the textbook definition of a disorder. More likely, they will fixate on a few symptoms but fail to mention others because they don’t think they are relevant. Knowing how to ask the right questions ensures these clues don’t go unmentioned. For clinical psychiatrists, a key part of every interview should center on the subject of sleep. While hypersomnia tends to be associated with major depressive episodes, insomnia is associated with far too many disorders to name, and most clinicians recognize that it is a good indication that the patient may be experiencing psychological distress . However, one type of sleep disorder that regularly escapes clinicians’ observation is obstructive sleep apnea. Recent research has shown that OSA is an independent risk factor for depression, anxiety, and more importantly cognitive decline/dementia, which is why it is vital that clinicians always ask their patients if they have been diagnosed with OSA or if they have some of the symptoms associated with the disorder. Obstructive Sleep Apnea at a Glance Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder in the world. It is estimated that 39 million adults in the United States have OSA and that the global figure is as high as 936 million. Risk factors for OSA include obesity, older age, male sex, a history of alcohol or tobacco use, a family history of OSA, and structural abnormalities in the throat or neck. OSA occurs when the throat muscles relax during sleep, leading to an interruption in the flow of air through the nose or mouth. The cessation in airflow is jarring enough to rouse a person from sleep so that they can reopen their airway, but the arousal is so brief that it does not get stored in memory. Patients with mild OSA tend to experience between five and ten apneic episodes per hour of sleep. In extreme cases, patients may experience over 30 episodes per hour. As far too many spouses know, the main symptoms of OSA are loud snoring with intervals where breathing ostensibly stops for a few seconds before resuming. In some cases, it can sound like the individual is choking. Patients with OSA tend to experience daytime sleepiness, fatigue, morning headaches, morning confusion, and decreased libido. Patients with OSA are also at an increased risk of medical problems, such as cardiac arrhythmias, hypertension, and metabolic syndrome. Evidence of Correlation The simple explanation for the association between psychiatric disorders and OSA is that our brain needs sleep to function properly. While most people need between seven and nine hours each night for optimal health, no one is going to develop a psychiatric disorder by sacrificing a few hours of sleep every once in a while. However, when one’s sleep is regularly disrupted due to OSA, there is a cumulative effect. A cross-sectional study from 2003 involving almost 19,000 participants revealed that patients with major depressive disorder are five times more likely to have OSA. Meanwhile, a 2023 study involving just under 10,000 individuals found that patients with OSA are 1.36-fold more likely to experience depression and that the severity of OSA positively correlates with depressive symptoms. A systematic review and meta-analysis published in 2020 showed a notably high presence of both depressive and anxiety symptoms among individuals with OSA—35 percent and 32 percent, respectively. A similar correlation is evident with respect to mild cognitive impairment and dementia. Older patients with OSA appear to be at a higher risk of both, with one study finding a 1.7-fold increase in risk among all participants. The risk was more pronounced among men with OSA in their 50s and women with OSA aged 70 years or older. The risk of impairment was found to be 6-fold greater and 3.2-fold greater, respectively. Potential Mechanisms Broadly speaking, research has indicated that these disorders can be traced back to two mechanisms: sleep fragmentation and intermittent hypoxia. Sleep fragmentation leads to increases in sympathetic nervous system activity, oxidative stress, and neuroinflammation. Sleep fragmentation also leads to decreases in vasomotor reactivity. Intermittent hypoxia occurs when patients with OSA are momentarily (but repeatedly) starved of oxygen over the course of the night. This can accelerate cerebral small vessel disease, leading to hypoperfusion (i.e., a lack of nutrients to an organ; in this case the brain), white matter integrity anomalies, gray matter loss, increased permeability of the blood-brain barrier, and neuroinflammation. These interrelated processes compound one another, resulting in neuronal damage, neurodegenerative processes, vascular depression, and cognitive impairment. Treating OSA The first line of treatment in obese patients with mild symptoms or only recently developed OSA should be lifestyle interventions with a combination of dietary changes and increases in physical activity, which should make them less prone to apneic episodes. In cases where an intervention is more urgent, continuous positive airway pressure (CPAP) can open breathing passages and prevent apneic episodes. If a specific abnormality of the upper airway is found, surgical intervention can take place. Special consideration should be given to older patients, as they are already at a greater risk of cognitive impairment and dementia—especially given the fact that obesity rates among seniors have nearly doubled within a generation. Screening for and treating OSA—as well as other sleep disturbances—can help stem neurodegeneration and decline. The important takeaway is that OSA can cause significant complications but that it is treatable. As clinicians, we need to take a more proactive approach to treating OSA in high-risk populations because it has the potential to balloon into a major public health problem. However, one problem is that proper sleep studies are rarely covered by insurance, making it difficult to formally diagnose OSA and obtain CPAP machines with the help of insurance. To provide symptom relief to patients who possibly have OSA, clinicians can encourage lifestyle modifications like those noted above. These changes carry no risk and involve no expensive devices, but still reduce the severity of OSA and improve patient quality of life. Note: This article originally appeared on Psychology Today .

Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type. Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals. Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted. “While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release. “This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added. The findings were published online on December 4 in JAMA Psychiatry . Psychotherapy Uptick Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress. Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted. To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States. The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year. The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access . Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress. Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals. Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively). After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%). A National Priority Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%). Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%). In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%). Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits . Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas. The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it. Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic , teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote. “The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson. “Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added. Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals. Study funding was not disclosed. Olfson reported no relevant disclosures. Note: This article originally appeared on Medscape .

TOPLINE: Study findings underscored that with regard to the risk for dementia in White individuals of British descent, there is no safe level of alcohol consumption. METHODOLOGY: A linear and non-linear mendelian randomisation (MR) analysis within a population of White British drinkers within the UK Biobank (recruited between 2006 and 2010) to explore the causal association between light-to-moderate alcohol consumption and the risk for dementia. Alcohol consumption was self-reported weekly/monthly intake of various types; alcohol consumption was categorised as safe (≤ 14 units/week) and unsafe (> 14 units/week) per Alcohol Change UK and UK Department of Health Guidelines. The primary outcome was all-cause dementia identified in hospital and mortality records. Cox models were utilised for convention analysis, linear/non-linear MR based on a genetic score calculated from 95 single-nucleotide polymorphisms from a meta-genome study of 941,280 Europeans. TAKEAWAY: Of 313,958 current drinkers consuming a median of 13.60 units of alcohol/week (interquartile range, 7.10-25.20), 1.7% (n = 5394) were diagnosed with dementia (an average follow-up was 13.2 years [SD, 20]). In all, 48.6% (n = 152,644) consumed > 14 units/week. Multivariate analysis demonstrated a J-shaped relationship between alcohol consumption and dementia risk in current drinkers; lowest dementia risk was associated with alcohol consumption of 11.9 units/week (men: 16.8 units/week, P = .04; women: 8.4 units/week, non-significant). Summary-level MR analyses confirmed a positive link between genetically predicted alcohol intake and dementia risk across genders (weight median, overall predictive hazard ratio [PHR], 2.41 [95% CI, 1.76-3.30; P < .001]; for men, PHR, 1.64 [95% CI, 1.19-2.24; P = .002]; for women, PHR, 2.13 [95% CI, 1.41-3.21; P < .001]). IN PRACTICE: "Our analysis found distinctly more significant association between alcohol consumption and dementia risk among women drinkers…[but] suggested that alcohol's impact on dementia results may be more evident in women, who typically had lower rates of other risk factors," the authors wrote. Nevertheless, "our findings suggested that there was no safe level of alcohol consumption for dementia." SOURCE: The study was conducted by Lingling Zheng, Shenzhen University of Advanced Technology, Guangdong, China, and appeared online in eClinical Medicine. LIMITATIONS: Limitations included potential biases due to confounders and reverse causality, self-reported alcohol consumption, missing confounders (eg, change in alcohol consumption over time), misclassification errors, and limited generalisability. DISCLOSURES: The study was partially supported by a Shenzhen Science and Technology Program grant and Strategic Priority Research Program of Chinese Academy of Sciences. The authors had no financial disclosures of interest. Note: This article originally appeared on Medscape .

Healthy Coping Skills for Uncomfortable Emotions Coping Strategies Coping Strategies are actions we take -- conciously or unconsciously - to deal with stress, problems, or uncomfortable emotions. Unhealthy coping strategies ten to feel good in the moment, but have long-term negative concequences. Healthy coping strategies may not provide instant gratification, but they lead to long-lasting positive outcomes. ​ Examples of unhealthy coping strategies: Examples of healthy coping strategies: • Drug or alcohol use • Exercise • Overeating • Talking about your problem • Procrastination • Healthy eating • Sleeping too much or too little • Seeking professional help • Social withdrawal • Relaxation techniques (e.g. deep breathing) • Self-harm • Using social support • Aggression • Problem-solving techniques Example Scenarios Scenario Discussion Questions • What consequences might result from this individual’s unhealthy coping strategy? • What healthy coping strategies could be helpful for the individual? • What barriers might be preventing the individual from using healthy coping strategies? Healthy vs. Unhealthy Coping Strategies Describe a problem you are currently dealing with: ​ My unhealthy coping strategies: ​ Consequences of unhealthy coping strategies: ​ 2. ​ Healthy coping strategies I use, or could use: Expected outcomes of healthy coping strategies: ​ Barriers to using healthy coping strategies: 1. ​ ​ 2. ​ ​ 3. ​ ​