Key points: Cannabis laws impact prescriptions for psych meds differently. Cannabis alters brain function, thereby altering the mind. The legalization of medical and recreational cannabis impacts prescriptions for psychiatric medications. Anxiolytic prescriptions are altered differently than antidepressant and antipsychotic prescriptions. Some legitimate questions cannot be researched using the “gold standard” of double-blind methodology needed to establish direct cause and effect. Instead, we need to rely on large computer databases and statistical analysis to provide perspective on the degree to which two events are associated with each other. A new study of over 10 million anonymized commercially insured patients looked at whether the use of anxiolytic (i.e., benzodiazepines), antidepressant, and antipsychotic medications is changed by state laws permitting the medical use, recreational use, or no legal use of cannabis.[i] The study’s authors proposed this would be a very interesting thing to know, "given perceptions about the potential effect of cannabis on individuals with mental health disorders.” In states, legalizing medical cannabis is associated with a 12.4% reduction in the fill rate of benzodiazepine prescriptions, and those states with legal recreational cannabis, legalization is associated with a 15.2% fill rate reduction. This reduction of benzodiazepine use is not surprising given the well-established fact that cannabis products generally have an anxiolytic effect for most people. This study suggests that people in states with the availability of legal cannabis offer an “over the counter” alternative to prescription benzodiazepines, which requires a physician’s ongoing approval. The ease of obtaining cannabis, along with its bonus sensations (from subtle to profound) could appeal to people who see no value in consulting an expensive physician or are embarrassed to do so. Furthermore, good medical practice encumbers benzodiazepine use with cautions regarding overuse and addiction while many cannabis dispensaries may issue no such warnings about their products. On the other hand, legalization of medical and recreational cannabis is associated with the opposite impact on antidepressant and antipsychotic prescriptions, though the major impact seems related to the legalization of medical cannabis and less to that of recreational cannabis. The opening of local legal medical cannabis dispensaries is associated with an 8.8% increase in antidepressant prescription fills. Prescriptions for antipsychotic medications increased by 2.5% after medical cannabis laws passed and by 2.5% when medical cannabis dispensaries opened. “Thus,” researchers concluded, “access to cannabis may represent a meaningful shift in mental health treatment for this population.” Any decrease in benzodiazepine use would potentially lead to fewer medically important negative consequences due to addiction, intended and unintended overdoses, and falls in the elderly. On the other hand, these positives might be counterbalanced by increased depression (see Cannabis, Depression, and Bipolar Disorder) and psychotic disorders known to be caused by use of high concentration THC cannabis products (see Cannabis Connection to Psychosis). In addition, there is always the risk of increasing cannabis addiction when more people use it (see Prevalence of Cannabis Use Disorder Among Cannabis Users). Bottom line: People are complex, as are mental health disorders and both prescription and non-prescription medications. Highly complex. The introduction of cannabis to the mix, whether it is termed medical (generally sold by non-medical entrepreneurs) or recreational, muddies the water for mental health workers. Cannabis is not candy, although it provides some of the same pleasures. It contains a large group of compounds that alter brain function, thereby changing mental experience, which is the point of people using it. As a result, mental health workers need to be told if you are using cannabis. And mental health workers need to understand the full implications cannabis use might have on patient treatment. Note: This article originally appeared on Psychology Today .

Day 3 Recap of the 2024 Mental Health America Conference Mental Health America wrapped up the third and final day of its annual conference with powerful programming that explored themes of novel approaches to substance use disorder, research informed by lived experience, student-led approaches to improving mental health on college campuses, and the vital role of spirituality in one’s well-being. It started with a keynote from Dr. Nzinga Harrison, Co-founder and Chief Medical Officer at Eleanor Health. Dr. Harrison, a psychiatrist, addiction medicine expert, author, speaker, and activist, emphasized a “culturopolitical” approach to mental health in addition to the traditional biopsychosocial model. Specifically, she discussed the importance of racism-informed care, which acknowledges the role that race-based trauma plays in an individual’s life. Dr. Harrison noted that healing may involve uncomfortable conversations. “The same way we want to point compassion to people who are seeking to start their journey to recover from addiction, we want to point compassion to people who are seeking to start their recovery from racism,” she said. Following the morning keynote, three breakout sessions looked at cutting-edge approaches to youth mental health, substance use disorder treatment, and mental health research. During a discussion titled, “Lift the Mask Club: A Student-Led Approach to Normalizing and Improving Mental Health on College Campuses,” three young mental health leaders, Emily A. Abbott, Ashley Panzino and Allie Rosenberg, discussed how mental health resources need to change along with young peoples’ brains when they leave high school for college. Sponsored by the Quell Foundation, the Lift the Mask Club initiative is a program created by college students for college students, helping them navigate difficult conversations and support each other. In a session called, “Breaking Barriers: Treating Dual Diagnosis with Ketamine and Novel Treatment Approaches,” Dr. Abid Nazeer, founder and Chief Medical Officer at Hopemark Health, outlined the promise of ketamine in helping address both psychiatric symptoms as well as underlying substance use. “When we talk about dual diagnosis, one principle matters most: Address both,” Dr. Nazeer said. “You tackle one only, and the outcomes go down. If you tackle both, you’ll have the best chance at success.” The MHA research team held a session titled, “Your Voice Matters: Integrating Lived Experience in MHA Research,” that explored how lived experience is integrated into both research as well as development of new technologies, such as the digital peer bridger tool for substance use. “With folks where I used to be, thinking what I was thinking: ‘There’s no way out,’” said Patricia Franklin, an MHA Board member and peer support specialist. “To tell someone my story, to see what I’ve come from and what I’ve been through, it could help somebody else and that’s what gets me excited.” The final keynote featured a highly anticipated conversation with Dr. Lisa Miller, a New York Times best-selling author and professor in the Clinical Psychology Program at Teachers College, Columbia University. Dr. Miller is also the founder and director of the Spirituality Mind Body Institute, the first Ivy League graduate program and research institute in spirituality and psychology, and has held over a decade of joint appointments in the Department of Psychiatry at Columbia University Medical School. Dr. Miller shared highlights of her groundbreaking work, which has shown the protective effects of spirituality on the brain’s well-being. “Depression and spiritual life are inextricably linked,” she said. “Despair is a gateway to awakening. Every one of us has this opportunity.” “That is your birthright. No one can ever take that away from you,” she added. Closing out the conference, MHA President and CEO Schroeder Stribling expressed gratitude to all who attended, including speakers, Board members and staff, for making it such a moving conference. “At Mental Health America, we together envision a future where everybody has an equitable opportunity for whole-person health, healing, and flourishing,” Stribling said. “And that is what you are doing.” Note: This article originally appeared on MHA National .

Mental Health America held the second day of main events at its 2024 Mental Health America Conference on Friday, beginning with music and conversation with the Me2/ Orchestra, the world's only classical music organization created for individuals with mental illnesses and the people who support them. The presentation was sponsored by Neurocrine Biosciences, Inc. Following the performance and panel discussion, four of Mental Health America’s young mental health leaders Makaila Davis, Anastasia Erley, Jonathan Jean Charles, and Kaisar Perry took the main stage, along with Vice President of Youth and Peer Advocacy, Kelly Davis. The group discussed what is lacking in current approaches to mental health and the importance of intergenerational collaboration that provides bidirectional mentorship and authentic relationships. “To me, intergenerational collaboration means combining the wisdom of older generations with the fresh ideas of younger ones to create more sustainable solutions in the mental health space,” said Makaila Davis. Jonathan Jean Charles encouraged attendees to “leverage the past, to inform the present, to make a brighter future.” At the conclusion of the panel, MHA’s mPower Award, which celebrates the life and work of a teen or young adult who has spoken out about mental health issues to educate peers and fight stigma, was presented to Ernesto Isaac Lara. In his acceptance, he emphasized the importance of representation and how meaningful it is to receive the award as a young, queer, grandchild of immigrants. He reminded attendees that his expertise is not dependent on his accolades or the institution he’s affiliated with, but on his own personal journey. "I am not an expert because of the institutions I work for, I am an expert because of my lived experience, and I'm gonna always stand on that,” Lara said. The mid-morning featured breakout sessions across the various conference themes of youth and young adult mental health; policy and advocacy; and community responses to disaster and humanitarian crises. One standout session was presented by 12-year-old Anisha Marrapu, Founder of BhavnaFoundation. Marrapu discussed her work using a machine learning model and resting-state EEG data to detect and treat psychiatric disorders early. “It is tremendous to learn that Anisha is twelve years old and is already working to help her peers in addressing their mental health,” said MHA’s Chief Social Impact Officer Dr. America Paredes, “Her efforts in developing diagnostic tools like the EEG to respond to early intervention and identification needs is remarkable and commendable. She is leading the way and reminds us to be hopeful for the future.” In the afternoon, actor Teddy Sears presented the 2024 MHA Media Awards . Winners included: Hawaii News Now: Hope for Hawaii Island, “I Need to Ask You Something,” “In Her Shoes,” The Awakenings Review, and MindSite News. The afternoon breakout sessions that followed featured topics like cannabis and psychosis, peer respite care, and supporting the mental health of marginalized LGBTQ+ youth. “When working with LGBTQ youth, replace judgment with wonder and meet people where they are,” said Phii Regis of the Human Rights Campaign Foundation during his presentation. Attendees gathered back at the main stage in the evening for a keynote address from Dr. Brian Anderson, CEO of Coalition for Health AI. Anderson addressed measuring reliability in AI, emphasizing the need for consensus on definitions and standards, including fairness, transparency, and robustness. He discussed the mental health field as a unique space for AI, with potential benefits in providing non-judgmental support and assisting people with patient advocacy. “I think certainly within the next two years, we're all going to have something on our phone that is AI-driven and potentially has the ability to ingest our health data if we wanted to,” Anderson said, “If the tools are trained appropriately right, and they're innate, able to align themselves to the kinds of values and priorities that you as an individual have, right, and it knows your health data, there's a real interesting space where each of us can have an advocate that never tires, that is always looking out for us, that perhaps is advocating for what we need or what we want, or helping us to advocate for what we need and what we want with our clinicians, particularly in the mental health space.” Following the keynote, three awards were presented. The Betty Humphrey Equity Champion Award, which recognizes those who advance the intersectionality of mental health as it relates to discrimination, poverty, stigma, racism, and overall social and economic determinants of health, was given to the Montgomery County Public Schools International Admissions & Enrollment Office's EML Therapeutic Counseling Team for the services they provide to emergent multilingual learners. The Joseph de Raismes III Policy Award, which honors an individual who – like de Raismes – makes outstanding contributions to furthering mental health policy, was presented to Barbara Johnston for her impactful advocacy work in mental health, deinstitutionalization, addiction, and crisis management. The George Goodman Brudney and Ruth P. Brudney Social Work Award, which recognizes significant contributions made to the care and treatment of people with mental illness by practicing professionals in social work, was presented to Dr. Joey Pagano for his profound empathy, compassion, and unwavering commitment to harm reduction. “I just believe in principles like self determination and…principles like meeting someone where they're at and just loving someone until they're ready to make that change and get the help they need,” said Pagano in his acceptance speech. The 2024 Mental Health America Conference continues through Saturday, Sept. 21. Note: This article originally appeared on MHA National .

CATEGORY 1 CME Premiere Date: September 20, 2024 Expiration Date: March 20, 2026 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 inform readers of how best to provide end-of-life care to patients with psychiatric disorder. LEARNING OBJECTIVES 1. Describe and discuss the nature and causes of hastened death in patients with psychiatric disorders, including foreseeably hastened death. 2. Describe potential roles for palliative care in psychiatric patients with treatment unresponsive late-stage psychiatric disorders. 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 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. Note: This article originally appeared on Psychiatric Times .

Mental Health America held the first day of main events at its 2024 Mental Health America Conference on Thursday with over 900 clinicians, advocates, and industry leaders attending in person and thousands across the country and globe virtually. The programming kicked off with remarks from MHA President and CEO Schroeder Stribling and Health Resources and Services Administration Administrator Carole Johnson at an opening luncheon. The afternoon featured breakout sessions across the various conference themes of mental health innovation; local solutions to equity needs; youth and young adult mental health; policy and advocacy; and community responses to disaster and humanitarian crises. When attendees gathered back at the main stage in the early evening, Mental Health America’s young mental health leaders joined Stribling and MHA Board Chair Pierluigi Mancini in an annual conference tradition: the ringing of the Mental Health Bell. During the early days of mental health treatment, asylums often restrained people who had mental illnesses with iron chains and shackles around their ankles and wrists. With better understanding and treatments, this practice stopped, and in the early 1950s, Mental Health America issued a call to asylums across the country for their discarded chains and shackles. In April 1953, at the McShane Bell Foundry in Baltimore, Mental Health America melted down these inhumane bindings and recast them into a sign of hope: the Mental Health Bell. Today, the Mental Health Bell rings out hope for improving mental health and achieving victory over mental illnesses. Following the bell ringing, Mancini presented Mental Health America’s highest award – the Clifford W. Beers Award. Created in honor of MHA’s founder, the award is presented annually to a consumer of mental health or substance use services who best reflects the example set by Beers in his efforts to improve conditions for and attitudes toward people with mental illnesses. Mancini presented this year’s award to Renee Jones, a dedicated mental health professional, speaker, and survivor advocate who overcame addiction and sex trafficking. “I fought and fought and fought and I will not stop fighting. I am here today to let you know that Mental Health America, you and I will continue to fight in the open and be there for the ones that cannot fight for themselves,” said Jones in her acceptance speech, invoking one of Beers’ most famous quotes, “I must fight in the open.” In the final event of the evening former Rep. Patrick J. Kennedy and Philomena Kebec sat down with MHA Board Member Madhuri Jha to discuss mental health advocacy and Kennedy’s latest book, “Profiles in Mental Health Courage,” which features Kebec’s story. Kebec, who belongs to the Bad River Band of Lake Superior Chippewa Indians, discussed how healing for her is not just about medication or therapy, but about making structural changes, including elevating people in her community who are experiencing injustice. “That is as much a part of my therapy as when I go and talk to my therapist every week,” she said. Kennedy echoed the need for systemic change and addressing social determinants of mental health saying, “We don’t treat the main factors in helping people have stability…housing, employment — these are things that aren’t covered by insurance.” He also called for political leaders and future presidential administrations to focus on mental health as a bipartisan issue. “We’ve got a much bigger fight, it’s not a republican or democratic fight, it’s about getting this issue front and center,” he said. The 2024 Mental Health America Conference continues through Saturday, Sept. 21. Note: This article originally appeared on MHA National .

How Do You Differentiate Between Fact and Opinion? Facts are verifiable statements. Opinions are personal interpretations of facts, which differ from person to person. For example, it is a fact that the sky is blue, and an opinion that the weather is beautiful. Despite knowing the difference between facts and opinions, your brain does not always differentiate between the two. Harmful opinions, such as “I’m a bad person,” are sometimes treated as fact. Even without evidence, these opinions may contribute to negative thinking, stress, and other problems. ​ Facts ​Opinion 1. I listened to my friend talk about their bad day. ​ ​ ​2. I am a good friend. ​ ​ ​3. I am ugly. ​ ​ ​4. I have a blemish on my face. ​ ​ ​5. My hair looks bad. ​ ​ ​6. My boss said that I did a great job on the project. ​ ​ ​7. No one will ever like me. ​ ​ 8. My crush said “no” when I asked them out. ​ ​ ​9. I’m not as smart as the rest of my class. ​ ​ ​10. I’m lazy. ​ ​ ​11. I watched TV instead of doing my homework. ​ ​ ​12. My friend is angry at me. I know this because they were frowning. ​ ​ ​13. My friend frowned. ​ ​ ​14. Everyone was bored during my speech. ​ ​ 15. I should always be nice. ​ ​

Teenagers and young adults taking high doses of prescription amphetamines may face a greater than fivefold increased risk of developing psychosis or mania, a new analysis suggests. The risk was highest with doses of ≥ 30 mg of dextroamphetamine, which corresponds to 40 mg of Adderall, investigators found. There was no association between new-onset psychosis or mania and past-month use of methylphenidate. "Stimulant medications don't have an upper dose limit on their labels, and our results show that it is clear that dose is a factor in psychosis risk and should be a chief consideration when prescribing stimulants, lead investigator Lauren Moran, MD, a pharmacoepidemiology researcher at McLean Hospital, Belmont, Massachusetts, said in a news release. "This is a rare but serious side effect that should be monitored by both patients and their doctors whenever these medications are prescribed," Moran said. The study was published online September 12 in the American Journal of Psychiatry. Clear Dose–Response Relationship Previous studies have identified an increased risk of psychosis with prescription amphetamines, but information on the impact of dose levels is limited. "This represents a major gap in knowledge in light of high rates of prescribing of this class of medications," write the researchers. To investigate, Moran and colleagues conducted a case-control study using electronic health records of Mass General Brigham patient encounters between 2005 and 2019, focusing on individuals aged 16 to 35, the typical age of onset for psychosis. They identified 1374 case individuals who presented with a first episode of psychosis or mania and 2748 control patients with a psychiatric hospitalization for other conditions, most commonly depression or anxiety. Overall, they observed a greater than twofold increased odds of psychosis and mania among individuals with past-month prescription amphetamine use (adjusted odds ratio [aOR], 2.68; 95% CI, 1.90 - 3.77). The likelihood of psychosis or mania with past-month prescription amphetamine use was increased by 5.3 times with doses exceeding 30 mg dextroamphetamine equivalents, which corresponds to 40 mg of mixed amphetamine salts and 100 mg of lisdexamfetamine. In sensitivity analyses comparing cases with outpatient controls, the odds of psychosis or mania were increased by 13.5 times with the highest dose level. Past-month use of methylphenidate was not associated with increased odds of psychosis and mania compared with no use (aOR, 0.91; 95% CI, 0.54 - 1.55), consistent with results from a 2019 study by Moran and colleagues. Risk Mitigation Strategies Investigators noted in the study that current guidelines on attention-deficit hyperactivity disorder (ADHD) treatment lack maximum doses and recommend clinicians target the dose to symptom control while avoiding intolerable side effects, "given the lack of evidence-based research supporting maximum doses." "Our findings suggest that clinicians can mitigate the risk of psychosis or mania by avoiding doses above 30 mg dextroamphetamine equivalents," they write. Commenting on the study for Medscape Medical News , Stephen Faraone, PhD, distinguished professor, Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, New York, noted that the US Food and Drug Administration already cautions that stimulants may cause psychosis. "These new data from a well-executed study provide some guidance about dose, which is helpful," Faraone said. However, because most study participants did not have ADHD, it's unknown if the data would apply to most people with that condition, he noted. "We also cannot tell if the stimulants were being used as prescribed," Faraone added. "Because some patients abuse their stimulants, that could account for some of the results." Faraone also cautioned that this was an observational study and, like all such research, is open to confounding. "The authors did a good job adjusting for available confounds but could not adjust for those that were not available such as severity of prior psychiatric disorders," Faraone said. Also providing perspective, Nina Kraguljac, MD, professor, Department of Psychiatry and Behavioral Health, Ohio State University College of Medicine in Columbus, felt the study was "very carefully" performed and the authors did a "very good job describing the limitations of the research." But as a researcher and clinician, my main takeaway is to be thoughtful when prescribing high doses of amphetamines for treatment of ADHD in younger populations, as the high-dose treatments can really increase the risk for psychosis," Kraguljac told Medscape Medical News. This is especially important in cases when there is an existing family history of psychosis or other serious mental illness, Kraguljac said, "or choose an alternative medication like Ritalin [methylphenidate] in people where you're concerned about family history of psychosis," she advised. This work was funded by a grant from the National Institute of Mental Health . Moran is employed by Sage Therapeutics (unrelated to this work and after the study was completed and submitted for publication). Faraone and Kraguljac have reported no relevant relationships. Note: This article originally appeared on Medscape .

Key Point: A new study of adult emergency department admissions found that individuals taking high doses of amphetamine—like Adderall—have a 5-fold increased risk for developing psychosis or mania. A new study of adult emergency department admissions at Mass General Brigham, led by McLean Hospital researchers, found that individuals taking high doses of amphetamine—like Adderall—have a 5-fold increased risk for developing psychosis or mania.1,2 According to investigators, individuals with past-month prescription amphetamine use had a greater likelihood of new-onset psychosis or mania than individuals without past-month use. The highest risk was seen in patients taking 30 mg or more of dextroamphetamine, which corresponds to approximately 40 mg of Adderall. While previous research linked stimulants to psychosis and mania risk, there was little information on whether dosing impacted risk. With prescribing rates for stimulants to treat attention-deficit/hyperactivity disorder (ADHD) at an all-time high, it is an important issue to note. “New-onset psychosis or mania is a rare but serious side effect of prescription amphetamines. Currently, US Food and Drug Administration labels do not have recommended upper limits on doses for the most commonly prescribed mixed amphetamine salts (Adderall). Our study found that doses higher than 30 mg dextroamphetamine equivalents, which is 40 mg of the mixed amphetamine salts (eg, Adderall), are associated with a more than 5-fold increase in the risk of psychosis or mania,” Lauren Moran, MD, a pharmacoepidemiology researcher at McLean Hospital and a member of the Mass General Brigham health care system, shared with Psychiatric Times . “Caution should be exercised when using high dose amphetamines, and we recommend screening for symptoms of psychosis or mania when patients need high doses of prescription amphetamines.” Investigators reviewed electronic health records of patient encounters at Mass General Brigham between 2005 and 2019, focusing on adults aged 16 to 35. All patients were admitted to McLean Hospital following referrals from other hospitals in the Mass General Brigham health care system. The researchers identified 1374 cases of individuals presenting with first-episode psychosis or mania, compared with 2748 control patients with other conditions like depression or anxiety. They conducted a comparison analysis of stimulant use over the preceding month and accounted for other factors, including substance use, to isolate the effects of stimulants. They found the attributable risk percentage among those exposed to any prescription amphetamine was nearly 63% and for high dose amphetamine was 81%. These findings suggest that among individuals who take prescription amphetamine, 81% of cases of psychosis or mania could have been eliminated if they were not prescribed the high dose. While a significant dose-related risk increase was seen in patients taking high doses of amphetamine, no significant risk increase was seen with methylphenidate (Ritalin) use. This is consistent with previous research. Limitations of the study include inconsistencies with how electronic health records are kept. Additionally, the findings may not be generalizable to the entire United states, as the research took place in a psychiatric hospital in the Boston area that sees many patients with psychosis. Moran shared that the current study was born out of her observations and experiences as an inpatient psychiatrist. “As a psychiatrist who treated patients on the schizophrenia and bipolar disorders inpatient unit at McLean Hospital, we were seeing patients admitted for new onset psychosis and/or mania in setting of prescription stimulant use, most commonly on high doses of prescription amphetamines,” Moran exclusively told Psychiatric Times. “I started doing research on this topic several years ago to raise awareness of this issue and determine what stimulant type was associated with higher risk. In previous work, we found that prescription amphetamine use was associated with a higher risk of psychosis than methylphenidate. The current work builds upon our prior work by finding a dose response effect.” Moran has a few ideas as to amphetamine alternatives, which she shared with Psychiatric Times: “Alternative strategies include use of methylphenidate, which was not associated with an increased risk of psychosis or mania, or using non-stimulants such as atomoxetine or guanfacine. The totality of evidence in this study (across main and secondary analyses) does not suggest there is an increased risk of psychosis/mania in individuals taking <= 15 mg dextroamphetamine equivalents (equivalent to 20 mg of Adderall). Behavioral strategies in combination with stimulants can be helpful, for example, working with patients on developing better time management skills.” While the current study does not prove causality, the investigators note there is a plausible biological mechanism in neurobiological changes that include a release of higher levels of the neurotransmitter dopamine from amphetamines, that parallel dopaminergic changes observed in psychosis. Moran said the findings need not create alarm but should lead to extra caution when these medications are prescribed, especially for those who have risk factors for psychosis and mania. “The risk of psychosis and mania is a rare side effect of stimulants, and there certainly are patients who may benefit from higher doses of amphetamine if they are still having significant impairment from ADHD symptoms . It is likely that individuals who have been on high doses for a long time without any significant side effects are at minimal risk. When using high dose amphetamines, I would recommend screening for symptoms of psychosis or mania. Having patients on high doses of amphetamines sign a release so you can talk to a family member could be helpful, as they can inform you of any concerning behaviors if they arise,” said Moran. Note: This article originally appeared on Psychiatric Times .

Key Point: Antidepressants posed "negligible" risk of inducing mania in bipolar depression, in a target trial emulation with a larger cohort than in RCTs that have assessed this effect. The risk of antidepressants inducing a switch to mania in patients with bipolar depression was found to be "negligible", in a 1-year nationwide target trial emulation.1 The study cohort was larger than in randomized controlled trials (RCTs) that have assessed the effect, and the length of follow-up longer than in most. "Although mania occurs frequently among patients with bipolar depression treated with antidepressants, our findings imply that this may not be caused by the antidepressants but rather by the recurrent nature of bipolar disorder," indicate Christopher Rohde, MD, PhD, and colleagues, Departments of Clinical Medicine and of Affective Disorders, Aarhus University, Aarhus, Denmark. While the investigators acknowledge limits on generalizing from their findings, they tout the target trial emulation and use of nationwide Danish health registers as a means to overcome the high costs and other challenges of conducting a comparable RCT. These include the requirement for high numbers of patients to be retained for statistical power throughout a sufficiently long term for mania to arise in the course of bipolar depression with and without antidepressant treatment . "This study demonstrates the power of using nation-wide register-based data for target trial emulations," said Rohde et al. "With a total sample size of 979 patients, this study was much larger than any of the previous antidepressant treatment trials with patients with bipolar depression, and it achieved good statistical power." In an accompanying editorial,2 Natalie Gottlieb, PhD, and Allan Young, FRCPsych, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK, agree with the investigators that using longitudinal observation data from the health registers, within comprehensive eligibility criteria and adjustment for baseline confounders, did overcome some shortfalls of the RCTs, but note that it poses other limitations. "Data that are not collected for research purposes may include inconsistencies, such as ambiguous medical coding and a lack of standardized measurements," Gottlieb and Young point out. "Additionally, they are unable to emulate RCTs with regard to placebo control or tight monitoring of treatment adherence." Target Trial Emulation Rohde et al drew on data from health registries to identify 979 patients 18 years or older who were discharged from their first psychiatric admissions with bipolar depression, in the period from January 1, 1996, through March 1, 2018. They excluded those who were previously diagnosed with bipolar depression or had used an antidepressant in the 2 years preceding the admission, as well as patients with previous diagnosis of schizophrenia or schizoaffective disorder. The antidepressant treatment group comprised 358 of the patients, identified for having filled a prescription for an antidepressant within 2 weeks after discharge. Among these, 181 were initially prescribed a selective serotonin reuptake inhibitor, 51 a tricyclic antidepressant, 41 a serotonin and norepinephrine reuptake inhibitors, and 85 received another antidepressant. They found that those treated with an antidepressant were more likely to have the index admission in an earlier calendar year, to receive a mood-stabilizing agent, to have severe (vs mild or moderate) bipolar depression, to have a prior diagnosis of unipolar depression, to be married and to be employed. The occurrence of mania over 1 year was compared between groups with or without antidepressant treatment, with adjustment for baseline covariables to emulate randomized open-label treatment allocation. Rohde et al reported no statistically significant associations between treatment with an antidepressant and the risk of mania (hazard rate ratio 1.08, 95% CI, 0.72-1.61); or in subgroup analyses of those treated with or without a concomitant mood stabilizing agent.In a secondary measure of the possible contribution of antidepressants to rapid cycling, there was no statistically significant association between antidepressant treatment and bipolar depression recurrence. The investigators acknowledged that the internal validity of this trial emulation is less than that of an ideally conducted double-blind RCT for several reasons, including less capacity to control for baseline confounders. In the baseline comparison, for example, they found that patients not treated with antidepressants more likely to have a more severe course of illness marked by such events as repeat admissions, increased outpatient contacts, and manic episodes. "This relationship may very well reflect clinicians' caution against prescribing antidepressants for patients with a higher probability of mania," they posited. "Indeed, a major limitation of the present study is the lack of direct information on factors that influence treatment decisions, particularly the severity of the previous and current mood episodes," Rohde et al observe. Gottlieb and Young note other considerations, including the difficulty in distinguishing between bipolar I and II in constituting the cohort of this trial emulation. "This distinction is of crucial interest because there is evidence that these groups may respond to antidepressants very differently," they point out. Both the investigators and the commentators agree that additional studies are required to optimize treatment strategies for individuals with bipolar depression. "It remains clear, however, that new efficacious treatments for bipolar depression are urgently needed," Gottlieb and Young state. Note: This article originally appeared on Psychiatric Times .

PSYCHIATRIC VIEWS ON THE DAILY NEWS Tonight is the US Presidential Debate and tomorrow is the anniversary of 9/11/01. About a month later comes the anniversary of 10/07/23. Such anniversaries, and the associated political processes, provide an opportunity to learn from 2 international traumatic conflicts, perhaps to even help prevent future large and smaller repetitions. It would be easy to blame the original perpetrators of these wars, and that has been done over and over. It is also easy to blame all sides and their accomplices, and that has been done, too. All of that makes justice challenging. However, we psychiatric professionals can look below the surface and, if we do, what can we find? The same culprit in so many wars and conflicts over history. As the cartoon figure Pogo rightly said in what has become a cliche: we have met the enemy and the enemy is us! The enemy is our human nature. Potentially, too, human nature is also the rescuer. How so? It is built into our human nature that we tend to fear the other. Probably way back in time, that was necessary for everyday survival. With a perceived and real danger, our fight, freeze, or flight response automatically kicks in with varying intensity, which can lead to scapegoating and a quest for power over the other(s). The other can be quite different in some important and noticeable way, or even similar, as in the Freudian concept of the narcissism of small differences. When humiliation of the other is involved, potential revenge is common, which can begin an ongoing intermittent cycle of conflict and violence. Forgiveness becomes elusive. There seems to be an example going back thousands of years, when the ancestors of Hamas and Israel came from the same territory and land, exemplified perhaps in the story of the 2 stepbrothers, Ishmael and Isaac, respectively, who were forcibly separated in their childhood and predicted to lead 2 peoples. That there is a wider psychological context now is suggested by the fact that both anti-Semitism and Islamophobia have been concurrently rising lately. The potential good psychological news is that the undue fears can be overcome cognitively with a lot of persistence, trust, compassion, and as much forgiveness as possible. We are quite familiar with cognitive behavioral therapy that reframes erroneous personal cognitive conclusions in patients, and a variation of that can be applied to undue fears. Moreover, child development offers an opportunity to learn how to process those fears more successfully. Teaching tolerance, as the “righteous gentiles” did during the Holocaust, goes a long way. Leadership is also crucial and Track 2 negotiations, as worked on by 2 psychiatrists, Vamik Volkan and now Neil Aggarwal, can enhance peace prospects.1,2 As in the ongoing tension between India and Pakistan, teaching the psychological aspects of cross-cultural relationships to those in higher level governmental, has promise to positively influence their country’s policies. I suppose that if all these interventions of rational thinking and psychiatric expertise do not have enough effect, or we give up on them, there is always faith, even faith for a miracle. It is common to view 7 as a divine number of completion, for the days of the week. Eleven tends to be a mystical number, too. The 7-Eleven convenience stores successfully played upon that, changing their name from Tote’m in the 1940s and then deciding to open at 7AM and close at 11PM. In dice gambling there is a phrase called “7 come 11,” which reflects gamblers’ optimism in the lucky power of rolling 7 to bring winning when connected with a follow-up 11. In Judaism, there is a concept called gematria, where hidden meanings of numbers are considered. Am I serious about relying on a paradoxical positive impact of the numbers of the days, 7 and 11, of the months of these 2 tragedies? Maybe, maybe not. What else could help bring more peace? Artificial intelligence? Psychedelics? One way or another, progress is required in our age of ever-increasing real weapons of mass destruction. A window of opportunity is still open. Note: This article originally appeared on Psychiatric Times .

by Kara Rowland, MHA Vice President of Communications Content warning: Suicide and suicidal ideation. If you or someone you know is struggling or in crisis, help is available. Call or text 988, or text MHA to 741741. It's been two years since the launch of the 988 Suicide & Crisis Lifeline, which provides free, confidential access to trained crisis counselors 24/7 for those in distress. To spread the word about 988 resources, advocates are teaming up this year for the very first 988 Day on Sunday, Sept. 8, with the theme of: "No judgment. Just help." The goal, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the agency that funds the 988 Lifeline, is to emphasize the importance of mental health and suicide prevention. Data shows that improving 988 awareness is more than a worthy goal–it’s a necessary one. Only 18% of adults reported being familiar with 988 resources, according to a 2023 KFF poll. Awareness is even lower among Black, Hispanic and Asian adults as well as those who don’t speak English very well. Yet the need for crisis support is as urgent as ever. In 2022, the U.S. recorded one death by suicide every 11 minutes, according to data from the Centers for Disease Control. Suicide was the leading cause of death for people ages 10-14 and 25-34. More than 13 million were estimated to have serious suicidal thoughts. Since launching in July 2022, 988 crisis counselors have answered more than 10 million calls, texts, and chats. Text continues to surge in popularity, with 1.7 million of those contacts initiated via text–a modality that saw a 51% increase from 2023 to 2024. While 988 wait times and answer rates have improved over time, challenges of course remain. That’s explained in part by the fact that the Lifeline is actually a nationwide network of more than 200 local crisis centers with varying levels of funding and other resources. (While SAMHSA funds 988 nationally and has supported implementation costs, states themselves are responsible for long-term funding of the crisis centers that power the Lifeline.) At MHA, we believe that a mental health crisis should receive a healthcare response, not a law enforcement one–which is why we advocated from the very beginning to pass legislation establishing 988 and now we fight for resources federally and in the states to increase the capacity of the 988 program and develop a continuum of crisis services when people need more support. But our policy work is only impactful if people know about the services that are available. For example, the 988 Lifeline includes sub-networks for Spanish speakers, veterans, and the LGBTQ+ community. In recognition of 988 Day, SAMHSA has created a free digital toolkit with everything from fact sheets and social media assets to event ideas in community settings. The agency is encouraging advocates to use the hashtag #988Day to share activities and promotional efforts. A social event wall will then aggregate them all in one place. As Health and Human Services Deputy Secretary Andrea Palm put it recently: “We have worked to champion a ‘no wrong door’ strategy for accessing help for mental health, but it’s clear there are still a lot of people who feel they have run out of options. My message to those who are struggling: you are not alone, we hear you, and we are here to help. 988 is an important resource and anyone who needs help should reach out.” If you or someone you know is struggling or in crisis, help is available. Call or text 988, or text MHA to 741741. You can find additional resources on the MHA website , including warning signs to look for and how to help a loved one who may be experiencing suicidal thoughts. Note: This article originally appeared on MHA National .

TOPLINE: A self-guided mobile application for cognitive behavioral therapy (CBT) is associated with significant reductions in anxiety in young adults with anxiety disorders after 3 weeks, with continued improvement through week 12, a new randomized clinical trial shows. METHODOLOGY: The study included 59 adults aged 18-25 years (mean age, 23 years; 78% women) with anxiety disorders (56% with generalized anxiety disorder; 41% with social anxiety disorder). Participants received a 6-week CBT program with a self-guided mobile application called Maya and were assigned to one of three incentive strategies to encourage engagement: Loss-framed (lose points for incomplete sessions), gain-framed (earn points for completed sessions), or gain-social support (gain points with added social support from a designated person). The primary end point was change in anxiety at week 6, measured with the Hamilton Anxiety Rating Scale. The researchers also evaluated change in anxiety at 3 and 12 weeks, change in anxiety sensitivity, social anxiety symptoms, and engagement and satisfaction with the app. TAKEAWAY: Anxiety decreased significantly from baseline at week 3, 6, and 12 (mean differences, −3.20, −5.64, and −5.67, respectively; all P < .001), with similar reductions in anxiety among the three incentive conditions. Use of the CBT app was also associated with significant reductions in anxiety sensitivity and social anxiety symptoms over time, with moderate to large effect sizes. 98% of participants completed the 6-week assessment and 93% the 12-week follow-up. On average, the participants completed 10.8 of 12 sessions and 64% completed all sessions. The participants reported high satisfaction with the app across all time points, with no significant differences based on time or incentive condition. IN PRACTICE: "We hear a lot about the negative impact of technology use on mental health in this age group," senior study author Faith M. Gunning said in a press release. "But the ubiquitous use of cell phones for information may provide a way of addressing anxiety for some people who, even if they have access to mental health providers, may not go. If the app helps reduce symptoms, they may then be able to take the next step of seeing a mental health professional when needed." SOURCE: The study was led by Jennifer N. Bress, PhD, Department of Psychiatry, Weill Cornell Medicine, New York City. It was published online on August 20 in JAMA Network Open . LIMITATIONS: This study lacked a control group and the unbalanced allocation of participants to the three incentive groups due to the COVID-19 pandemic may have influenced the results. The study sample, which predominantly consisted of female and college-educated participants, may not have accurately represented the broader population of young adults with anxiety. DISCLOSURES: This study was funded by the NewYork-Presbyterian Center for Youth Mental Health, the Khoury Foundation, the Paul and Jenna Segal Family Foundation, the Saks Fifth Avenue Foundation, Mary and Jonathan Rather, Weill Cornell Medicine, the Pritzker Neuropsychiatric Disorders Research Consortium, and the National Institutes of Health. Some authors reported obtaining grants, receiving personal fees, serving on speaker's bureaus, and having other ties with multiple pharmaceutical companies and institutions. Full disclosures are available in the original article. Note: This article originally appeared on Medscape .