Key Takeaways "Crazy" is a complex term with dual connotations, reflecting both derision and praise, akin to historical literary reversals of values. American culture's "trickle-up effect" influences global perceptions, exporting psychiatric concepts and cultural elements worldwide. The series will explore "crazy" through popular culture and philosophy, challenging the dominance of rationalism and technology in understanding mental health. A deeper understanding of madness is advocated, beyond traditional psychiatric frameworks, incorporating cultural, historical, and philosophical perspectives. SECOND THOUGHTS Mad, bad, and dangerous to know. – Lady Caroline Lamb on Lord Byron In the 19th century, the most common expression for irrationality and insanity was “madness,” as the English poet Lord Byron’s lover attested. In this century, it is probably “crazy”—which we will get to shortly. But what exactly did Lady Caroline Lamb mean? She seems to have made sure she covered several possibilities—not just mad but bad—and dangerous to boot. And today, “crazy” seems to cover all of them, which is why we need to deconstruct its meaning. Another late 19th century figure of English literature, Samuel Butler wrote a novel called Erewhon (“nowhere” backwards) that is classified as utopian fiction. We can also read it as a satire on Victorian British society and a visionary attempt to extrapolate Darwin’s evolution to the industrial revolution to imagine machine consciousness and self-replicating machines. His themes could be ripped out of today’s headlines. As a psychiatrist, however, the most provocative idea in Erewhon is the satirical reversal of attitudes to crime and illness. In Erewhonian law, offenders are treated as ill and sick individuals are treated like criminals. Either way, Lady Caroline Lamb had Byron covered! In Erewhon, Butler portrays this reversal with scenes of neighbors visiting the family of an offender with flowers and condolences while someone who falls ill is treated with avoidance and scorn. Nothing in the entire utopian/dystopian genre since Thomas More’s Utopia (“nowhere” in Greek, published in Latin in 1516) is more striking than this reversal of values, reminiscent of German philosopher Friedrich Nietzsche’s “transvaluation of all values” and recalls George Orwell’s Newspeak in Nineteen Eighty-Four where everything is the opposite of its ascribed name.4 The Ministry of Truth, for example, is concerned with lies. “The Trickle-Up Effect” In English today, we use the word crazy much more often than mad in an expansive popular take on “madness.” And like the reversals in Butler’s and Orwell’s dystopias, crazy can now be a term of derision and dismissal, condescension and disqualification on one hand, or on the other hand, approval, even praise, and an invitation to a different, transgressive way of being (eg, the songs “Crazy” by Seal and “Let’s Get Crazy” by Prince). Two things are top of mind in this series and they are both very American. The first, which I enjoy, is America’s secret cultural strength: how things bubble up from lower classes, from the street to mainstream culture. “Bottom up” instead of “top down” like the European culture of symphonies and operas. Think about the music that spawned from the American underclass and its marginalized groups: New Orleans’ ragtime, jazz, blues, rhythm and blues, rock’n’roll, and Detroit’s Motown and New York’s hip-hop. Think about Hollywood’s noir films that went from B movies to cult classics. Think about lowrider culture in East LA. In the opposite of trickle-down economics, we can call it the “trickle-up effect.” The incarnation of the American dream. One of the striking things about my professors of philosophy is their marriage of high and low culture. Not just analyses of Greek myths like “Antigone” (one of my favorites) or Verdi’s opera “Aida” (another favorite) but English rocker David Bowie (Simon Critchley), Russian feminist protest group Pussy Riot (Slavoj Žižek), and Valerie Solanas’ radical feminist “SCUM Manifesto” (Avital Ronell). Slavoj Žižek edited a book called Everything You Wanted to Know About Lacan (But Were Afraid to Ask Hitchcock) where Hitchcock’s thrillers are used to explore concepts in Lacanian psychoanalysis. Simon Critchley has a column on philosophy called “The Stone” in The New York Times and has participated in and written about the punk movement in England. The queen of this approach is Avital Ronell at New York University, who was a student of Algerian French philosopher Jacques Derrida, and applies his deconstructive method to popular culture. She investigates things that appear in the margins like the “SCUM Manifesto” and the everyday notion of “stupidity” which is like a “black hole devouring the light of rationality” (as a reviewer wrote). In this way, Ronell takes on the “repressed conditions of knowledge” and makes them accessible and relevant for the mainstream and for philosophy. “Crazy Like Us” The second thing is more equivocal and that is how America exports its culture worldwide in what political scientists call “soft power.” Hollywood movies, American music from rock’n’roll to hip hop, fast food (see my column on fast food and slow thought), and how we imagine health and mental health. American journalist Ethan Watters describes this in his book, Crazy Like Us: The Globalization of the American Psyche. In it, Watters points to the rise of anorexia in Hong Kong, the American invention and spread of posttraumatic stress disorder, and other cases. I would argue that not only does the West’s most powerful centripetal culture dominate psychiatry and mental health worldwide, but that its fads, obsessions, and blind spots get exported along with our best intentions. Going Deep by Staying Shallow In this new series in “Second Thoughts,” I will explore what we mean by crazy through popular culture (going deep by staying shallow) and the humanities (cinema, history, literature, philosophy)—all with a psychiatrist’s eye. And how the reciprocal relationships between American psychiatry and popular culture create a product that gets exported around the world. The Global Mental Health Movement may have started elsewhere but it is now fully embraced by academic psychiatry and funding sources in Canada and the US, and my North American colleagues are spreading this with messianic zeal. We are going to have some fun with this. Yet, just in case you think it is not serious, we will also revisit the anti-stigma campaigns that I see as part of social psychiatry’s “public works projects.” And we will try to understand the push by those who call themselves “progressives” towards the enlightenment project of progress through rationality and science. My question about that is: When did science (and a narrow and restrictive notion of science at that) become the measure of all things? For there is a dark side to this progressive rationalism in which we see a general intolerance for what is subjective and irrational. As Neil Postman, America’s foremost critic of education and media put it in his masterful polemic Technopoly, defined as the surrender of culture to technology, “Technopoly is at war with subjectivity.” The real intolerance towards those with mental illness, in my view, is not that we are ill-informed or prejudiced (we are, including psychiatrists, sometimes). Rather, that there is no room in a society dominated by technology and a narrow view of science for real diversity and subjectivity, not to mention eccentricity, playfulness, and satire. No amount of political correctness about the neurodivergent has really moved the needle on public acceptance of diversity. Individuals on the autistic spectrum have become the object of comedy (think of Sheldon Cooper, the eccentric genius of “The Big Bang Theory” TV series). As a social philosopher, “crazy” offers an apparatus or tool to study how ideology takes root to colonize the popular imagination, creating hegemony with this fluid yet pernicious cultural category. I will define these key words. As a psychiatrist, “crazy” (and “insane” which may be more offensive) overlaps imperfectly with the subject of psychiatry. Schizophrenia, coined by Eugen Bleuler, MD, in 1908, is the medical psychiatric version of “crazy.” As the central psychiatric term of the 20th century, schizophrenia has been called “the sublime object of psychiatry.” Along the way, we will examine French philosopher Michel Foucault’s Madness and Civilization (which may well be the trigger that made me want to become a psychiatrist after Marcel Lemieux, MD, introduced me to him 50 years ago [see my column: “The Revolving Door”]) and other histories of psychiatry and madness. We will separate histories: the history of psychiatry, the history of the social and cultural construction of madness (which is what Foucault attempted), and finally, the history of the lived experience of madness which has been undertaken by the social sciences, historians, and humanists, with very limited results. What is new and refreshing in this is the voice of individuals experiencing mental, relational, and social suffering themselves. We will also revisit Derrida’s deconstruction and other tools for doing philosophical archaeology, digging down deep into our cultural origins to root out how we came to think and feel the way we do about something like “crazy.” Finally, beyond deconstruction, we desperately need a philosophy of madness, and we will review the dense work of Wouter Kusters, a brave Dutch philosopher and linguist who offers just that. My next column will take on a popular view of “crazy.” “Crazy, manic, twisted, suicidal, psychotic”—this is a view of psychiatry through one of the most important vehicles of culture in our time: popular music. Or, Everything you wanted to know about crazy, but forgot to ask your DJ. Get ready for “Help!” (The Beatles), “Suicide Is Painless” (the M.A.S.H. theme), “Manic Depression” (Jimi Hendrix), “19th Nervous Breakdown” (The Rolling Stones), and “Psychotic Reaction” (The Count Five). Note: This article originally appeared on Psychiatric Times .

Older adults who are sensitive to the distress of others are more likely to feel anxious or depressed themselves because of a psychological mechanism called “emotional contagion,” researchers suggested. Emotional contagion is an adaptive response that occurs unconsciously when people mimic the facial expressions, gestures, and postures of others, leading to a convergence of emotions. “Just as some people are more likely to catch a respiratory virus through close contact, others are more susceptible to ‘catching’ the emotions of the people around them,” said Marie-Josée Richer, PhD, a psychoeducator at the University of Montreal, Montreal, Quebec, Canada. Vulnerability to emotional contagion emerged as the strongest factor contributing to psychological distress in Richer’s cross-sectional study of 170 older adults who were dealing with adversity. Those who were most vulnerable to emotional contagion were 8.5-10 times more likely to present symptoms of anxiety or anxious depression than those who were less vulnerable. This research is part of a series of studies on stress contagion led by Pierrich Plusquellec, also of the University of Montreal and principal investigator of the current study. “We aimed to explore elements of contagion among older adults in light of the known physiological changes in their ability to regulate stress and emotions and the daily contexts of proximity, such as caregiving and community living in a retirement home, which may increase opportunities for emotional contagion,” Richer told Medscape Medical News. The study was published online on October 29 in PLOS Mental Health . Dealing With Adversity Researchers explored a wide range of factors — sociodemographic aspects, indicators of autonomy, social support, coping styles, vulnerability to emotional contagion, and empathy — to assess which ones most influenced two profiles of psychological distress and one profile with no distress. This cross-sectional study included 170 older adults (mean age, 76 years; 85% women) living in a community setting in Quebec. Sixty percent lived alone, 90% completed at least secondary school, and most had annual incomes between $21,000 and $60,000. All participants were dealing with some type of adversity, which was defined as challenges, obstacles, or difficult conditions such as bereavement or conflict with a spouse (explicit adversity) or vulnerability to emotional contagion (implicit adversity). As assessed by the Hospital Anxiety and Depression Scale, 65.9% of participants had a clinical or subthreshold level of anxiety and depression. Based on the scale’s clinical cutoff scores for the anxiety and depression subscales, the researchers grouped participants according to one of three profiles: No distress, anxiety (44% of participants), and anxious depression (21%). All between-group demographic indicators were similar except for sex: There was a slightly higher-than-expected proportion of men in the anxious depression group. Vulnerability to emotional contagion, satisfaction with their social network, and coping styles emerged as factors that increased the likelihood of being in either of the psychological distress groups, relative to individuals with no distress. All groups differed in perceived stress due to adversity. Individuals with no distress symptoms reported significantly less stress than those in the other two groups. Those with anxiety symptoms alone reported less stress than those with anxious depression. In addition, the use of medication to treat anxiety or depression was higher than expected for those in the anxious depression group. After controlling for adversity and psychotropic treatment, vulnerability to emotional contagion had the strongest relationship with both psychological distress profiles. This was a “surprising” result, according to Richer. Coping styles also differed between the groups. Overall, participants in the anxious depression group used less proactive, reflective, strategic planning, preventive, and emotional support strategies than those in the other two groups. The authors acknowledged that recruitment bias could have affected the results, given that more than 75% of the sample lived in high-end private residences. In addition, the cross-sectional design of the study precluded speculation on causation. Nevertheless, they concluded, “Our results support the value of interventions like programs aimed at improving satisfaction with one’s social network and enhancing the cognitive mastery of emotional contagion to reduce or prevent psychological distress in the growing aging populations.” “When supporting individuals experiencing psychological distress, assessing the emotional state of their social environment — rather than just its level of support — seems essential,” said Richer. “A deterioration in the emotional state of the social environment, combined with an increased vulnerability to being affected by others’ emotions, could also serve as an indicator of mental health risk. “We believe it may be possible to teach individuals how to better navigate the positive and negative impacts of emotional contagion,” she continued. “The first step would involve psychoeducation about this type of adversity and its role. The second step would focus on emotional regulation and coping strategies to help individuals manage the emotions they absorb from others.” Good Emotions, Too? Commenting on the study for Medscape Medical News , Alan Cohen, PhD, associate professor of environmental health sciences at Columbia University Mailman School of Public Health in New York City, said, “This makes some sense, but probably susceptibility to emotional contagion works for good emotions, too, and has benefits earlier in life.” He cited better social skills, better ability to gauge the mood of a crowd, and more empathy as examples. “Natural selection probably maintains a balance and diversity of emotional contagion capacities in human populations, and there are likely pros and cons to being anywhere on the spectrum,” he said. “Maybe the right ‘treatment’ would be to expose these people to positive emotional environments. They should benefit the most,” he added. “But further research is needed to see if [emotional contagion] really is symmetrical for good and bad emotions, and if not, what it means.” Note: This article originally appeared on Medscape .

TOPLINE: Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks postpartum is linked to greater reductions in depressive symptoms . METHODOLOGY: Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants. The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety. Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise. Data sources included online databases with data up to January 2024, reference lists, and hand searches. The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence. TAKEAWAY: Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], −0.52; 95% CI, −0.80 to −0.24). Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, −0.25; 95% CI, −0.43 to −0.08). Initiating exercise within 12 weeks postpartum was associated with a greater reduction in depressive symptoms compared with starting later. Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95). IN PRACTICE: “Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote. SOURCE: This study was led by Margie H. Davenport, University of Alberta in Edmonton, Alberta, Canada. It was published online in British Journal of Sports Medicine . LIMITATIONS: This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings. DISCLOSURES: This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. Stephanie-May Ruchat is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors. Note: This article originally appeared on Medscape .

Key Takeaways Lithium showed a trend towards reducing suicide risk, but results were not statistically significant in the meta-analysis of seven RCTs. The study found moderate-quality evidence supporting lithium's potential to lower mortality rates, despite statistical insignificance. Clinicians should consider lithium for suicide prevention, taking into account patient-specific risk factors and characteristics. Further research is necessary to clarify lithium's long-term antisuicidal effects and its impact on impulsivity reduction. TRANSLATING RESEARCH INTO PRACTICE Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor A monthly column dedicated to reviewing the literature and sharing clinical implications. There is some controversy regarding lithium’s ability to prevent suicide. Given the challenges related to suicide research, specifically that rates of death by suicide are so low that a very large sample size is needed to achieve statistical significance, it is difficult to measure suicide in a single study. Relatively small sample sizes limited previous systematic reviews. This column reviews a systematic review and meta-analysis of 7 randomized controlled trials (RCTs), including a recent RCT that enrolled over 500 participants. The aim was to provide clarity on lithium’s efficacy in suicide prevention . The Study Riblet NB, Shiner B, Young-Xu Y, Watts BV. Lithium in the prevention of suicide in adults: systematic review and meta-analysis of clinical trials. BJPsych Open. 2022;8(6):e199. Study Funding This study was funded by the Veterans Affairs National Center for Patient Safety Center of Inquiry Program in Ann Arbor, Michigan. Study Objectives To assess the efficacy of lithium in preventing suicide. Methodology This study was a systematic review and meta-analysis of RCTs exploring the effect of lithium on suicide. Systematic review followed Cochrane guidelines, and the investigators searched the literature from January 1, 2015, to November 30, 2021, using 5 databases: MEDLINE (via Ovid), Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials (CENTRAL), and PsycInfo. Additionally, references of the included studies were reviewed, and ClinicalTrials.gov was searched for additional studies. Eligibility criteria included RCTs with adults older than 18 years assigned to lithium or control (placebo, usual care, or waitlist) and reporting death by suicide as a primary or secondary outcome. There were no restrictions on language. Studies were included regardless of suicide events and were not limited by diagnostic condition. The efficacy of lithium vs control for preventing death by suicide was evaluated by calculating the OR with 95% CI and P values using the Peto method. Statistical significance was defined as P less than .05 and 95% CI not crossing 1. Heterogeneity was assessed using the Cochran Q test and the I2 statistic, with substantial heterogeneity defined as P less than .10 and I2 greater than 50%. Additional review of the data included confirmatory analysis using a Poisson regression model with random effects and calculating an incidence rate ratio (IRR) for suicides over person-years. Publication bias was assessed by generating a funnel plot for the primary outcome and visually inspecting for asymmetry. Quality of evidence was assessed using GRADEpro software. Ethics approval and informed consent were not required for this study. Study Results The systematic review yielded 7 RCTs that met eligibility criteria, comparing lithium with control using death by suicide. All studies were conducted in North America or Europe from 1973 to 2022 and involved adults with a diagnosis of major depressive disorder or bipolar disorder. The odds of suicide were lower for the 568 individuals on lithium compared with the 570 in the control group (OR, 0.30; 95% CI, 0.09-1.02; P = .05), although the difference was not statistically significant. The IRR also favored lithium (IRR, 0.22; 95% CI, 0.05-1.05; P = .06), but this result was similarly not statistically significant. No substantial or significant heterogeneity was observed among the studies (Cochran Q, 3.60; I2 = 0%; P = .61). One study (Girlanda 2014) had a wide CI and favored the control group, which was care as usual. All other studies favored the intervention group and used a placebo as the control group. Risk of bias assessment indicated concerns about study assignment and adherence due to reported nonadherence to the study drug and high attrition rates. Recruitment issues were also noted in several studies. A visual inspection of the funnel plot showed no evidence of publication bias. In the case of 1 participant death by drug overdose, the authors conservatively decided not to include this as a suicide. Had they included this death as a suicide, the study would have reached statistical significance and more strongly favored lithium. According to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) analysis, the certainty of the evidence in favor of lithium was moderate, highlighting its importance in relation to mortality outcomes. Conclusions The 7 RCTs included in this systematic review and meta-analysis found that the odds of suicide were lower in individuals treated with lithium . However, these results were not statistically significant. Practical Applications This study provides moderate evidence that lithium lowers the risk of suicide . Clinicians should consider lithium as an intervention to reduce suicide risk. More data are needed to clarify the long-term antisuicidal effects of lithium and its role in decreasing impulsivity. Bottom Line This systematic review and meta- analysis aimed to provide clarity on an important topic in psychiatry: preventing suicide . Although the results were not statistically significant, this review had moderate-quality evidence supporting lithium’s ability to lower mortality rates. Clinicians should consider the unique risk factors, characteristics, and values of their patients when considering utilizing lithium in the treatment of suicidal patients. Note: This article originally appeared on Psychiatric Times .

Every relationship has disagreements. It’s how we handle those disagreements that counts. A bad argument can turn even a little problem into a big one, making it emotionally charged and painful. This is where fair fighting rules come in. Fair fighting rules don’t tell us we can’t argue. Instead, they tell us how to do it safely. They tell us what’s okay—and what’s crossing the line—in an argument. More Fair Fighting Rules Worksheet Video Communication Techniques Worksheet Worksheet Worksheet

TOPLINE: Brief cognitive behavioral therapy (BCBT) even when delivered remotely via video telehealth effectively reduces suicide attempts among high-risk adults. METHODOLOGY: The researchers conducted a randomized clinical trial to compare BCBT and present-centered therapy (PCT) for prevention of suicide among participants receiving care at an outpatient psychiatry and behavioral health clinic in the United States from April 2021 to September 2023. A total of 96 adults (mean age, 31.8 years; 66.7% women) were randomly assigned to receive either BCBT, which teaches skills for emotion regulation and reappraisal (n = 51), or PCT, which assists participants in increasing adaptive responses to stressors (n = 45). Therapy sessions were conducted remotely via telehealth , including an intake session and 12 weekly outpatient individual sessions, with follow-up assessments at 3, 6, 9, and 12 months. The primary outcome was the number of suicide attempts, assessed using the Self-Injurious Thoughts and Behaviors Interview — Revised, a validated self-report instrument. The secondary outcome was the severity of suicidal ideation, assessed using the Scale for Suicide Ideation, a psychometrically validated self-report tool. TAKEAWAY: During the 1-year follow-up, participants receiving BCBT made fewer suicide attempts (mean attempts per participant, 0.70; 95% CI, 0.49-1.00) than those receiving PCT (mean attempts per participant, 1.40; 95% CI, 1.07-1.84). Participants receiving BCBT had a 41% reduced risk for suicide attempts compared with those receiving PCT (hazard ratio, 0.59; P = .03). Both therapy groups experienced significant reductions in the severity of suicidal ideation (P < .001), with no significant difference between the groups. IN PRACTICE: “The present results provide further support for the effectiveness of BCBT for preventing suicide attempts among adults with elevated risk for suicide and indicate the treatment’s effect on reducing suicide attempts is preserved when delivered remotely via video-based telehealth,” the authors wrote. Note: This article originally appeared on Medscape .

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment. Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted. "We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit," study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia, told Medscape Medical News. The findings were published online on November 11 in JAMA Neurology . A Promising Biomarker An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role. To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582). The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline. Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included. Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances. Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts. After adjusting for potential confounders, frailty scores were modeled using backward time scales. Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort. When measured on a timeline, as compared with those who didn't develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC). Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted. In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk. Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association. In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort. The 'Four Pillars' of Prevention The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention. To slow the development of frailty, Ward suggested adhering to the "four pillars of frailty prevention and management," which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network. Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning. Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia . Unclear Pathway Commenting on the findings for Medscape Medical News , Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer's Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation. The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study. "Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline," she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease. Note: This article originally appeared on Medscape .

Key Takeaways Magstim's Horizon Inspire TMS system is FDA-cleared for MDD, OCD, and anxious depression, offering a nonpharmacological treatment alternative. TMS is increasingly used for patients unresponsive to traditional treatments, with insurance coverage expanding to include Medicare. The Inspire system provides customizable, portable, and cost-effective TMS treatments, supported by extensive research and advanced data analytics. Magstim's Horizon 3.0 system features advanced navigation technology, enhancing treatment precision and simplifying clinical workflows. Magstim just announced that the US Food and Drug Administration (FDA) has granted clearance to its Horizon Inspire transcranial magnetic stimulation (TMS) system to treat major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and anxious depression. “Physicians, nurse practitioners, and mental health care professionals tell us that patients are searching for alternatives to pharmaceutical treatments,” said Ronnie Stolec-Campo, the CEO of Magstim. “FDA-cleared TMS is a proven and effective treatment with minimal side effects. We designed the Inspire to enable both experienced TMS providers as well as those who are new to TMS.” The use of TMS for treating MDD and OCD is increasing, driven by new studies demonstrating its effectiveness over other treatments. One-third of patients with MDD experience inadequate response to pharmacotherapy and psychotherapy. After 2 failed antidepressant trials, a different therapeutic modality might be beneficial, including TMS. The Inspire system allows clinicians to provide easy to use, cost effective, portable, high-power, air-cooling, back-to-back customizable TMS treatments. The Inspire system is built using Magstim TMS technology, which is cited in more than 20,000 peer reviewed research papers. It is used in hospitals, clinics, and research centers worldwide. The system also leverages intuitive preset clinical workflows to simplify the treatment process, and delivers precise results with no pulse decay, ensuring the correct dosage. Magstim’s air-cooled coil reduces downtime and eliminates additional cooling expenses. Furthermore, its advanced data analytics tools improve the efficacy of the treatment. TMS is now mostly covered by insurance, including Medicare. Additionally, the range of clinicians available to utilize TMS has expanded: many states now permit both psychiatrists and psychiatric nurse practitioners to prescribe and treat patients with TMS. Earlier this year, the FDA granted clearance to Magstim’s TMS technology, Horizon 3.0 with StimGuide Pro, which is indicated for adults with MDD who failed to achieve improvement from prior antidepressant trials, and for adults with OCD. Horizon 3.0 with StimGuide Pro is the first integrated TMS system with navigation, adding new advanced camera technology designed to allow for precise treatment targeting and a central screen intended to reduce complexity. The Horizon 3.0 TMS Therapy System has also received prior clearance for decreasing comorbid anxiety symptoms in adults with MDD. “We are passionate about helping patients worldwide to improve their mental health,” said Stolec-Campo. “We worked with leading psychiatrists, clinicians, and researchers to develop this system, enabling advanced treatments and simplified practice workflows. TMS is life-saving technology that provides nonpharmacological, noninvasive treatments.” A psychiatric provider, Khaled Bowarshi, MD, also shared this about Magstim’s products: “Our TMS patients have experienced a high-degree of success, allowing them to change their lives. We strive to provide the best technology for our patients.” “Magstim engineered the very first commercially available TMS research technology, and we remain committed to our foundation of research,” said Stolec-Campo. “We are unique in the industry because we do not charge pay per use fees, we maintain a dedicated service and support team, and we manufacture our own technology.” Note: This article originally appeared on Psychiatric Times .

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson of the Yale School of Medicine. We've got to talk about kids' access to guns. I know this is a charged issue. In this space, I often editorialize; I give my thoughts and impressions of a medical study with an understanding that reasonable discourse is still possible, at least when it comes to healthcare. But guns are different. Some of you may think an associate professor of medicine and public health is a great person to discuss the gun issue, as it is firmly a medicine and public health problem. Some of you may think guns have absolutely nothing to do with either of my specialties and that I should stay in my lane. But I don't want to avoid this. We don't know all the details surrounding the most recent school shooting, in Georgia, but we do know that the weapon used by the 14-year-old shooter had been in his home. Some reports suggest that it was actually his gun, given to him as a gift from his father. And this week, we have some hard data on how gun owners with kids think about the relationship between kids and guns. Let's try to figure this out. Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson of the Yale School of Medicine. We've got to talk about kids' access to guns. I know this is a charged issue. In this space, I often editorialize; I give my thoughts and impressions of a medical study with an understanding that reasonable discourse is still possible, at least when it comes to healthcare. But guns are different. Some of you may think an associate professor of medicine and public health is a great person to discuss the gun issue, as it is firmly a medicine and public health problem. Some of you may think guns have absolutely nothing to do with either of my specialties and that I should stay in my lane. But I don't want to avoid this. We don't know all the details surrounding the most recent school shooting, in Georgia, but we do know that the weapon used by the 14-year-old shooter had been in his home. Some reports suggest that it was actually his gun, given to him as a gift from his father. And this week, we have some hard data on how gun owners with kids think about the relationship between kids and guns. Let's try to figure this out. I think the best thing I can do with this subject is stick to the facts as much as possible and flag carefully where I am drawing inference. So let's get started. Fact No. 1 : Firearm-associated injuries are the leading cause of death in children and adolescents in the United States, outpacing motor vehicle accidents since 2020. A bit more than half of these are deaths from suicide. Fact No. 2 : Children with guns in the home are more likely to die from suicide. This meta-analysis from the Annals of Internal Medicine estimated that the risk for completed suicide is 3.2 times higher when a gun is in the home, and the risk for homicide is two times higher. Fact No. 3 : Studies show that four storage practices are associated with a lower risk of a child being harmed by a gun in a home: Guns should be locked safely, stored unloaded, and stored in a different location than ammunition, which should also be locked. Each of these factors was associated with a 50%-70% reduction in the risk of a child being harmed by a firearm. Looking at these data, it makes me think of the concept of "responsible gun ownership." Just to be clear, I'm moving out of facts and into inference now. None of these reductions are 100%. Given the risk associated with owning a gun in a house with children, is there a way to do it safely? Truly safely? Or is that a pipe dream? Is it akin to talking about "responsible tiger ownership" or something? One thing I have heard from gun owners — and yes, while I do not personally own a gun, I am friends with quite a few people who do — is that when there are kids in the home, responsible gun ownership is not just about locking guns away safely. It's about teaching kids what responsible gun use looks like and providing clear guidance on when and how gun use is acceptable. And that sounds pretty good to me; a little education is never a bad thing. Unless that education gives parents a false sense of security. And that's what has me worried after reading this paper, "Parental Engagement With Children Around Firearms and Unsecure Storage," from JAMA Pediatrics , which came across my desk this week. This is a rather simple survey study, a representative sample of gun-owning adults with children in their home, from nine states, which I've shown here. The survey was fairly detailed, going into the type of firearm, the characteristics of the parents and the family, as well as the storage of the guns. Overall, you can see that a majority of parents reported discussing firearm safety with their kids. Half had demonstrated proper firearm handling. A third had taught their kids how to shoot a firearm. This is all fine — until you look at the association between teaching your kids about guns and safe gun storage. What the authors found was striking: Parents who said they taught their kids about proper firearm handling, or taught their children to shoot a firearm, were up to twice as likely to have at least one gun unlocked and loaded in the house. That's the data. The inference is that these parents feel safer having educated their children about guns, and thus feel more comfortable leaving a loaded gun unlocked. This scares me a bit because the data linking safe storage of firearms with safe kids are so strong. But the data we don't have is the relative impact of unsafe storage among gun-educated vs -uneducated children. There's an argument to be made that maybe these kids are fine, that they know enough about the gun to respect the gun. But we'd do well to remember that kids make mistakes. Kids are impulsive and irrational. Kids can develop depression, schizophrenia, and psychosis without their parents being fully aware. And a kid who knows how to use a gun, and who has free access to a gun, may in fact be particularly dangerous in the right circumstance. That's an inference, of course. But the facts remain clear. There are millions of kids living in houses with guns. These kids are at higher risk of dying from a gun. Safe storage mitigates that risk. Whether education mitigates the risk of unsafe storage remains an open question. We can always say wait for more data, but the precautionary principal is pretty clear on this one. If you own a firearm and you have a child in the house, no matter how well you've taught that child to respect the weapon, how knowledgeable they are about it, how safe they have demonstrated they can be with it, please lock it up — unloaded — and lock ammo up elsewhere. Keep the tiger in the cage. Note: This article originally appeared on Medscape .

A recent survey found mental health and finances were some of the top stressors for college students. Q&A It is back to school season, and while this can be an incredibly exciting time for some students, it can also be very stressful. College students in particular face a complex challenge: student loan debt. According to a recent nationwide survey of over 1200 college students, mental health (55%) and personal finances (32%) are among the top 5 stressors for this group, joined by physical health (40%), academics (31%), and inflation/rising prices (25%).1 Psychiatric Times sat down with Seli Fakorzi, MA, LPC-S, director of Mental Health Operations at TimelyCare, to discuss the impact of debt on youth mental health and how clinicians can help. PT: How do you think student loan debt affects college student mental health? Fakorzi: Students face a mountain of pressures competing for their time and energy daily. A nationwide survey found finances are a top stressor for college students.1 Whether it is one major challenge or a number of competing pressures, when a student becomes overwhelmed, it affects their lives in multiple ways—including their academic performance. PT: Does the cancellation of student loan debt forgiveness after having it promised worsen the situation? Fakorzi: Students have been stressed about their financial situations long before a student loan debt forgiveness plan was introduced, and we expect they will remain stressed even after its cancellation. That is why it is critical to remove financial barriers to care and provide resources for students so they can find the mental health and wellness support they need, when they need it. PT: How should mental health clinicians address student loan debt with their student patients? Fakorzi: These tips stand for clinicians supporting college students with any personal financial stress, not just stress from student loan debt: -Provide resource guidance . Encourage students to make a financial plan and offer them support to find a trusted financial planner or advisor who can help guide them through that process . -Foster community . Chances are that students are experiencing similar situations—especially when it comes to student loan debt. We know the -way students cope and find support for their mental health is through their peers. Encouraging students to connect with peers can make them feel less alone. -Encourage students to manage stress . This looks different for everyone—for some, that includes practicing self-care. For others, it means hitting the gym a few days a week to exercise. Asking students where they find stress relief and encouraging them to practice that multiple times per week is important. PT: There have been several landmark Supreme Court decisions surrounding colleges/universities, most recently with affirmative action. Do you think this time of change increases back-to-school stress? Fakorzi: There will always be stressors out of students’ control and outside influences that will impact student mental health and well-being. The good news is that colleges and universities realize that the student mental health crisis is far from over, and they continue to invest in resources that help bolster on-campus resources to support student health and well-being, ultimately leading to better engagement and academic performance. Ms Fakorzi is director of Mental Health Operations at TimelyCare. Related Article: Seasonal Patterns Identified for Suicidality in Children, Teenagers Among Children, Mental Disorders Associate With Gender, Family Income, Obesity

Today, I learned a lot about the reality of human trafficking and the underlying exploitation that exists….I attended the Refugee Mental Health and Wellness Conference… Human trafficking is a multifactorial issue, as it can be local or global in nature, depending on who and how someone is caught. One of the most common tactics to draw youth into the country is coercion…Opportunistic individuals lurking in society…portray their goodwill and desire to help unfortunate people achieve their dreams…which is a total lie… They are essentially anti-social, “salesmen” that prey on vulnerable humans that are seeking out a glimpse of hope…From my knowledge and understanding today, they “sell” people in third world countries the idea that they will bring these individuals to America to fulfill their dream…typical example would be going to Brazil and scouting out 15–16-year-old girls from low socio-economic backgrounds…selling them on the concept of becoming a model in the US. After charging them an arbitary amount $5–6K, then coach them to hopefully be successful during the VISA. Its a number game, as the value of each human life does not matter to these ruthless individuals, who exploit young teens. Upon entry into this country, they literally trap the person into a world of “slavery”, by charging them an additional $15–20K, upon entry into this country. As a result, it encroaches on the idea of modern day “slavery” as these people are unable to pay the debt. Left with no other choice, they are forced into sex trafficking, to pay off this debt. However, they are charge ridiculous amounts of interests, which results in entrapment. The person is trapped in a vicious cycle of servitude, where they are charged an exorbitant amount of money for the “help” they received. They are used and “serve” their “master” who entrapped them into this country, with no hope of escape. Unfortunately, based on the nature of the departure from their home country, they have loose or limited ties to their family on origin. At times, there are 30–40 people in 1200–1400 sq. foot homes, in one bathroom, with their rights, liberties, and freedoms are revoked. Their basic necessities are neglected are their body and brain are put their so much trauma at the expense of living this “false American dream”. These young teens live such impoverished lives which revolves around prostitution, drugs, mental illness (strongly influenced by recurrent trauma), isolation, major financial debt, and no hope of escaping their vicious cycle. Many individuals continue to have sequela of trauma as a result of human trafficking, which completely alter the course and direction of their life. They are unable to maintain any sense of regularity, as they are constantly trying to escape their violent, vicious thoughts, which blossom into underlying personality traits, if not disorders. I use to think that only certain areas were affected by human trafficking, which is far from the truth. I learned through a detective that I met, that some of worst pimps run their operations from surbuban settings.I guess, today I gained an awareness that the crime next to drug/guns is human trafficking. I think thats why I enjoyed seeing children for mental health issues…to target or prevent any underlying cycle of worsening mental health…hoping to influence or strongly alter the course of a young child’s life from a family dynamic and holistic perspective. I think children are so amazing but they need responsible authoritative parents, good mentors, coaches, teachers Source: Medium: Dr. Vilash Reddy

Keypoint: In this CME article, learn more about how to assess the impact of alcohol and cannabis use on anxiety treatment outcomes, recognizing potential adverse effects and interactions. CATEGORY 1 CME Premiere Date: August 20, 2024 Expiration Date: February 20, 2025 This activity offers CE credits for: 1. Physicians (CME) 2. Other All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered. ACTIVITY GOAL To engage readers in an introductory review of the common issues pertaining to comorbid anxiety disorders and alcohol and cannabis use so that they gain insights into effective screening strategies and intervention approaches. LEARNING OBJECTIVES Learn to assess the impact of alcohol and cannabis use on anxiety treatment outcomes, recognizing potential adverse effects and interactions. Learn about evidence-based behavioral interventions, including cognitive behavioral therapy and motivational interviewing, tailored to address co-occurring anxiety and alcohol/cannabis use. TARGET AUDIENCE This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders. ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource,® LLC, and Psychiatric Times.® Physicians’ Education Resource, LLC, is accredited by the ACCME to provide continuing medical education for physicians. Physicians’ Education Resource, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is funded entirely by Physicians’ Education Resource, LLC . No commercial support was received. OFF-LABEL DISCLOSURE/DISCLAIMER This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource, LLC. FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION The authors report that they were supported by grants from the National Institute on Alcohol Abuse and Alcoholism (K24AA025703), the National Institute of Mental Health (K23MH126078), and the National Institute on Drug Abuse (T32DA007250). Otherwise, none of the staff of Physicians’ Education Resource, LLC, or Psychiatric Times or the planners or the authors of this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. HOW TO CLAIM CREDIT Once you have read the article, please use the following URL to evaluate and request credit: https://education.gotoper.com/activity/ptcme24aug . If you do not already have an account with PER®, you will be prompted to create one. You must have an account to evaluate and request credit for this activity. Many individuals with anxiety disorders use alcohol or cannabis for temporary relief of worry, sleeplessness, tension, and other typical anxiety symptoms. For some, this coping response can lead to worsening anxiety and impairment over time. Common anxiety disorders and related conditions such as generalized anxiety, panic, social anxiety, and posttraumatic stress disorder (PTSD) also are correlated with the development of substance use problems. Prevalence estimates suggest that 15% to 20% of individuals with anxiety have a substance use disorder (SUD),5,6 with alcohol and marijuana being the most commonly used substances. Nearly 1 in 5 individuals with anxiety report using alcohol to cope with symptoms. Adults with anxiety are 2 to 3 times more likely to use cannabis compared with the general population, with rates increasing post legalization. The following is a review of how the use of alcohol and cannabis may complicate anxiety treatment. Given the widespread consumption of alcohol and cannabis, the review will include some ways clinicians can recognize and treat problematic levels of use. Many patients with both anxiety and substance use problems seek treatment in mental health rather than addiction treatment settings, highlighting the importance of psychiatric clinicians in addressing these co-occurring conditions. SUDs and Anxiety Disorders SUDs are characterized by difficulty controlling use despite serious consequences for one’s life or health. In DSM-5-TR, SUDs are categorized as mild, moderate, or severe. Risky alcohol or cannabis use that falls short of a SUD can still complicate a patient’s anxiety treatment, although consumption parameters describing risky use are better defined for alcohol. The current recommended alcohol use limits from the National Institutes of Health are 1 drink per day (or 7 per week) for women and 2 drinks per day (or 14 per week) for men. Patients with anxiety disorders may be better off drinking even less. Older adults and those with comorbidities such as diabetes and high blood pressure have increased vulnerability. In addition to worsening anxiety symptoms, alcohol use—even at low levels—has the potential to reduce the effectiveness of anxiety disorder treatment through adverse medication interactions or interference with exposure-based behavioral interventions. Cannabis continues to become more accessible and socially accepted due to increasing state-level legalization, which currently includes 24 states and the District of Columbia. Results of a recent survey indicate that individuals consider daily cannabis use and secondhand smoke safer than tobacco smoke. In contrast with alcohol, thresholds that mark unhealthy cannabis use can be difficult to define, especially given the variety of cannabis modes of use, strains, and potency levels. Initial research suggests that although cannabis use (ie, less than once a month) is not associated with anxiety treatment outcomes, heavier cannabis use (ie, 2 or more times per week) is associated with poorer outcomes. Some patients may see their cannabis use as helpful in reducing anxiety—a view that is supported by results from limited retrospective studies. Nevertheless, although cannabis and other substance use may indeed provide short-term relief from anxious symptoms, it is important to note that reliance on substances to calm anxiety may limit opportunities for patients to learn more adaptive strategies to manage anxiety, such as emotion regulation skills. Psychiatric clinicians should discuss these complex issues around cannabis use with patients in an open manner. This includes acknowledging potential benefits experienced by patients while assessing and educating patients about aspects of use that may conflict with patients’ anxiety management goals. For example, while dosing considerations for cannabis depend on several factors (eg, mode of use or product strength), key information to share with patients includes findings that higher doses (12.5 mg) of tetrahydrocannabinol (THC), a psychoactive ingredient in cannabis, can be associated with increased anxiety and that the average THC content in cannabis products has increased over the past 2 decades. Anxiety disorders are associated with both cannabis use ( OR, 1.24) and cannabis use disorder (1.68), with greater frequency of cannabis use associated with greater odds of psychosis (risk ratio: 1.10 for monthly use, 1.35 for weekly use, 1.76 for daily use), and past-year use demonstrating greater odds of panic disorder compared with individuals who did not use cannabis in the past year (unadjusted OR, 1.2-2.3). In addition, ingesting large amounts of cannabis can induce anxiety. Screening and Assessment Many relatively brief screening instruments are available and well-validated to identify problems with alcohol, cannabis, and other commonly used substances, such as the patient-reported (and easily administered) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). ASSIST consists of 8 questions covering tobacco, alcohol, cannabis, and other drugs. A risk score (low, moderate, or high) is provided and can be used to consider intervention level (eg, brief advice to reduce use or a more extensive approach). The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool is a similar instrument designed to be self-administered on a computer in health care settings. It also yields risk scores. For both alcohol and cannabis, clinicians should ask patients about quantity and frequency of use, symptoms of cannabis or alcohol use disorder, and any other problems they may have encountered. It is also useful to explore beliefs about anxiety-related effects or benefits and other motivations for alcohol or cannabis use. Other helpful details from the patient would include drinking frequency above recommended limits and the extent to which the patient uses alcohol to manage anxiety symptoms. When assessing cannabis use, some additional relevant considerations include the extent of daily use and age of first use, given that more frequent use and use at younger ages (eg, during adolescence) are consistently associated with worse mental health outcomes compared with occasional use and older age of starting to use. The clinical interview can also assess quantity of use and THC potency based on patients’ perceptions or the information they obtain from product labels. Intervention Strategies Clinicians can use several evidence-based approaches to help patients with anxiety reduce problematic alcohol and cannabis use. Behavioral intervention strategies such as cognitive behavioral therapy (CBT) and mindfulness training can be applied to both anxiety symptoms and substance use, and they can be effective in teaching patients new coping skills. Meta-analyses of intervention studies have indicated that CBT for SUD has a moderate to large effect size, indicating strong evidence for efficacy (eg, d = .45; g = .80), whereas mindfulness-based interventions, such as mindfulness-based relapse preventions, have small to medium effects (eg, d = .37-.58). Pharmacological treatments are more established for alcohol use than they are for cannabis, but new compounds are actively being tested. Recommended dosages are titrated based on a variety of patient factors and should be determined on a case-by-case basis. Lastly, promising digital therapies such as mobile apps can help patients manage anxiety and track and reduce substance use over time. A systematic review indicates a range of effect sizes and evidence quality regarding the efficacy of apps for substance use (d = .17-.70). Thus, we recommend using apps that have strong quality of evidence and have undergone more rigorous testing. For patients willing to engage in structured behavioral interventions, CBT is a helpful treatment approach for either cannabis or alcohol use problems. Principles of CBT such as learning new behavioral and thought patterns, tracking behaviors, and managing avoidance are relevant to both anxiety and substance use treatment. Typical CBT protocols for SUD range from 8 to 14 sessions. Sessions focus on increasing awareness of antecedents and consequences of substance use and leveraging behavior-change principles to reduce or eliminate substance use through environmental and social reinforcement. Throughout treatment, individuals learn about processes that underlie substance use, with an emphasis on understanding the thoughts and behaviors associated with their substance use, and gain skills to modify unwanted behaviors. In doing so, individuals become better equipped to identify and cope with triggers, challenge thoughts that precipitate use, manage high-risk situations, and reinforce behaviors that align with their recovery goals. Patients can be guided to understand how substance use may worsen anxiety and how to find room for alternative coping behaviors (eg, pleasant activities, mindfulness meditation). Many manualized CBT interventions address both substance use and anxiety disorders. Motivational interviewing (MI) is another key strategy for addressing cannabis use and unhealthy drinking that can be integrated into mental health care settings. MI is a patient-centered collaborative style of communication useful for strengthening motivation and commitment to change. Using MI, clinicians can help evoke reasons for change, resolve ambivalence, and move to action around reducing alcohol and cannabis use. Open-ended questions can help clinicians explore patients’ ambivalence related to reducing substance use and reinforce self-efficacy and “change talk” associated with anxiety coping that does not involve substances. Mindfulness-based relapse prevention also may be valuable in reducing substance use and building skills to manage anxiety. Common across mindfulness-based and exposure-based therapies is a focus on building interoceptive awareness—eg, awareness of one’s body signals—and observing them without judgment instead of avoiding them or fearing them. For example, patients may be advised to practice mindfulness when experiencing substance cravings and to increase present-moment awareness. Medications to help reduce alcohol use can be useful, especially in conjunction with CBT,5,although medication development for cannabis has been less successful. Selective serotonin reuptake inhibitors (SSRIs) can help with comorbid anxiety and alcohol use problems. Gabapentin has demonstrated positive effects on alcohol treatment outcomes, mood symptoms, and sleep. Topiramate can reduce the frequency of alcohol use and cravings as well as PTSD symptom severity. Naltrexone and disulfiram have been effective in treating patients with PTSD and alcohol use disorder, showing a reduction in alcohol use and symptoms of PTSD . Naltrexone is often the first choice to specifically address alcohol use cravings, and at least 3 to 4 months is a reasonable trial period. Clinicians should be mindful of specific potential interactions between medications (eg, psychiatric medications and disulfiram). However, alcohol use medications generally are well tolerated and can potentially be used in combination with medication for anxiety (eg, as in prior research on naltrexone and sertraline). Despite the testing of new compounds, there are no currently approved medications for the management of cannabis use disorder. This gap makes the use of behavioral interventions particularly important for the comorbidity of cannabis and anxiety. Some work suggests that active cannabis use can counteract the efficacy of SSRIs and increase the risk of adverse effects. Cannabis affects how the liver breaks down these medications, leading to higher doses in the bloodstream. Several mobile apps to reduce anxiety are available, and others focused on alcohol and cannabis use are in different stages of testing.The small number of established apps to help treat SUD includes reSET and reSET-O, which use cognitive behavioral and contingency management principles to target substance use generally (reSET) as well as opioid use disorder specifically (reSET-O). These apps are cleared by the US Food and Drug Administration as SUD digital therapeutics and are available to prescribe for insurance reimbursement. The Step Away app is focused on reducing unhealthy alcohol use (whether through moderation or abstinence) and is based on principles of motivational enhancement, relapse prevention, and community reinforcement. These emerging tools may be especially helpful for patients without access to other forms of treatment. Concluding Thoughts Cannabis and alcohol use are often associated with anxiety, and these combined problems may be challenging to manage. Screening in psychiatry is essential because patients are more likely to seek mental health care than they are to seek addiction treatment. Although there is a need for additional intervention development, behavioral strategies such as MI and CBT can reduce alcohol and cannabis use in those with anxiety. Medications to help reduce unhealthy alcohol use are well established and should be more widely offered in mental health settings, whereas medications to reduce cannabis use have yet to show efficacy. Despite wide availability, the generally unregulated status of apps has prompted new approaches to understanding available products. Guidelines from professional organizations such as the American Psychiatric Association can be useful in staying up-to-date on new mobile app developments and informing patients and clinicians about emerging treatment options. Note: This article originally appeared on Psychiatric Times .