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An intermittent fasting (IF) diet and a standard healthy living (HL) diet focused on healthy foods both lead to weight loss, reduced insulin resistance (IR), and slowed brain aging in older overweight adults with IR, new research showed. However, neither diet has an effect on Alzheimer's disease (AD) biomarkers. Although investigators found both diets were beneficial, some outcomes were more robust with the IF diet. "The study provides a blueprint for assessing brain effects of dietary interventions and motivates further research on intermittent fasting and continuous diets for brain health optimization," investigators led by Dimitrios Kapogiannis, MD, chief, human neuroscience section, National Institute on Aging, and adjunct associate professor of neurology, The Johns Hopkins University School of Medicine, wrote. The findings were published online on June 19 in Cell Metabolism . Cognitive Outcomes The prevalence of IR — reduced cellular sensitivity to insulin that's a hallmark of type 2 diabetes — increases with age and obesity adding to an increased risk for accelerated brain aging as well as AD and related dementias (ADRD) in older adults who have overweight. Studies reported healthy diets promote overall health, but it's unclear whether, and to what extent, they improve brain health beyond general health enhancement. Researchers used multiple brain and cognitive measures to assess dietary effects on brain health, including peripherally harvested neuron-derived extracellular vesicles (NDEVs) to probe neuronal insulin signaling; MRI to investigate the pace of brain aging; magnetic resonance spectroscopy (MRS) to measure brain glucose, metabolites, and neurotransmitters; and NDEVs and cerebrospinal fluid to derive biomarkers for AD/ADRD. The study included 40 cognitively intact overweight participants with IR, mean age 63.2 years, 60% women, and 62.5% Caucasian. Their mean body weight was 97.1 kg and mean body mass index (BMI) was 34.4 kg/m2. Participants were randomly assigned to 8 weeks of an IF diet or a HL diet that emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy and limits added sugars, saturated fats, and sodium. The IF diet involved following the HL diet for 5 days per week and restricting calories to a quarter of the recommended daily intake for 2 consecutive days. Both diets reduced neuronal IR and had comparable effects in improving insulin signaling biomarkers in NDEVs, reducing brain glucose on MRS, and improving blood biomarkers of carbohydrate and lipid metabolism. Using MRI, researchers also assessed brain age, an indication of whether the brain appears older or younger than an individual's chronological age. There was a decrease of 2.63 years with the IF diet (P = .05) and 2.42 years with the HL diet (P < .001) in the anterior cingulate and ventromedial prefrontal cortex. Both diets improved executive function and memory, with those following the IF diet benefiting more in strategic planning, switching between two cognitively demanding tasks, cued recall, and other areas. Hypothesis-Generating Research AD biomarkers including amyloid beta 42 (Aβ42), Aβ40, and plasma phosphorylated-tau181 did not change with either diet, a finding that investigators speculated may be due to the short duration of the study. Light-chain neurofilaments increased across groups with no differences between the diets. In other findings, BMI decreased by 1.41 kg/m2 with the IF diet and by 0.80 kg/m2 with the HL diet, and a similar pattern was observed for weight. Waist circumference decreased in both groups with no significant differences between diets. An exploratory analysis showed executive function improved with the IF diet but not with the HL diet in women, whereas it improved with both diets in men. BMI and apolipoprotein E and SLC16A7 genotypes also modulated diet effects. Both diets were well tolerated. The most frequent adverse events were gastrointestinal and occurred only with the IF diet. The authors noted the findings are preliminary and results are hypothesis generating. Study limitations included the study's short duration and its power to detect anything other than large to moderate effect size changes and differences between the diets. Researchers also didn't acquire data on dietary intake, so lapses in adherence can't be excluded. However, the large decreases in BMI, weight, and waist circumference with both diets indicated high adherence. Note: This article originally appeared on Medscape .

There is a bidirectional, causal relationship between mental illness and poverty, new research showed. "This study indicates that certain mental health problems can make a person's financial situation uncertain. But conversely, we also see that poverty can lead to mental health problems," study investigator Marco Boks, MD, PhD, corresponding author, Amsterdam University Medical Center, Amsterdam, the Netherlands, said in a press release. The findings were published online on July 10, 2024, in Nature Human Behavior . Disentangling Cause and Effect Previous research shows a correlation between poverty and mental illness, but the direction of the association has always been uncertain and complicated by factors such as stress, housing insecurity, and substance use. To investigate a potential causal relationship between poverty and mental illness, investigators used data from more than 500,000 participants in the UK Biobank and the international Psychiatric Genomic Consortium, including 18 genome wide association studies. Investigators developed a measure of poverty based on household income, occupational income, and social deprivation. They then examined the causal relationship of poverty on nine mental illnesses. These included attention-deficit hyperactivity disorder (ADHD) , anorexia nervosa (AN), anxiety disorder, autism spectrum disorder, bipolar disorder, major depressive disorder (MDD), obsessive-compulsive disorder, posttraumatic stress disorder, and schizophrenia. They also extended the analyses to potential confounders such as cognitive ability. Using genomic structural equation modeling, the team found a causal bidirectional relationship between poverty, ADHD, and schizophrenia. They found that lower income was causally related to these disorders and that there was also a causal relationship between the disorders and lower income. They also found a one-directional causal effect of poverty on MDD and an inverse causal relationship between poverty and AN, which was causally associated with higher incomes (all P < .05). "This evidence supports a vicious cycle between poverty and severe mental illness," the authors noted. The effects of poverty on mental illness were reduced by approximately 30% when investigators adjusted for cognitive ability. The investigators noted that the generalizeablity of the findings are limited because most of the genetic studies were conducted in populations of European ancestry from high-income countries. In addition, they noted that psychiatric phenotypes are complex and heterogeneous, which generally translates to low power. "The findings of this study reiterate the need to further unravel the roles of poverty and mental illness and to use this insight to advance mental health for all. The choice of which action to take to address the problem is a political matter, but attention is warranted considering increasing income inequalities worldwide, as well as the increasing incidence of mental illness," the researchers noted. Note: This article originally appeared on Medscape .

Keypoint: Clinicians should carefully weigh the risks and benefits of each prescribed medication for an older adult with neuropsychiatric diseases and periodically review all prescribed medications. Learn more here. SPECIAL REPORT: POLYPHARMACY Older adults, defined as individuals older than 65 years, are vulnerable to drug-induced adverse effects due to age-related physiological changes, such as decreased renal and hepatic function, increased body fat, lower total body water, and lower lean body mass, all of which can impact the pharmacodynamics and pharmacokinetics of medications and increase the elimination half-life. Older adults experience a higher prevalence of comorbid chronic conditions, such as diabetes, heart disease, arthritis, and other psychiatric conditions. Nearly 95% of older adults have at least 1 chronic condition, and nearly 80% have or more. Polypharmacy is common given multiple medical comorbidities, but exposure to multiple medications may further lead to harm due to inappropriate medication prescription. The World Health Organization defines polypharmacy as “the administration of many drugs at the same time or administration of an excessive number of drugs.” Surprisingly, there is no consensus on the medication threshold and definition of polypharmacy. However, it is commonly described as the concomitant use of or more medications. For older adults, polypharmacy can be associated with increased poor health outcomes due to increased risk of falls, drug-drug or drug-supplement interactions, medication nonadherence, hospitalizations, and death. Findings from a recent meta-analysis examining the prevalence of polypharmacy and factors associated with polypharmacy showed that individuals older than 65 years had a higher prevalence of polypharmacy when compared with data from studies with individuals younger than 65. Additionally, there were lower estimates of polypharmacy in community settings when compared with outpatient and hospital settings, with overall results showing that older age and inpatient settings were associated with a higher prevalence of polypharmacy. Although consensus is unclear on the definition of polypharmacy in psychiatry, one common definition is the use of or more psychiatric medications, further broken down into categories (eg, or more medications of the same class, multiclass, adjunctive, augmentation, and total pharmacy). The estimated prevalence of polypharmacy in older adults hospitalized for psychiatric illness/disorders is as high as 80%. Not surprisingly, findings from a recent study examining the rates of polypharmacy in older adults with and without dementia showed that the median number of medications for adults with dementia was, compared with in those without dementia. Similarly, data from a meta-analysis examining the association between polypharmacy and depression showed an increased prevalence of polypharmacy in individuals with depression. Older adults with psychiatric comorbidities are particularly vulnerable to polypharmacy and adverse outcomes. In clinical practice, it is often challenging to avoid polypharmacy, particularly in older adults with treatment-resistant diagnoses necessitating augmentation strategies that would require multiple psychotropic medications. However, using the fewest possible medications and the simplest dosing regimen can help reduce the number of drugs prescribed, along with ongoing evaluation of indication, drug-drug interactions, and linking of each medication with a diagnosis. Overall, research findings have indicated that inappropriate polypharmacy can affect up to one-third of the population, with polypharmacy becoming a substantial health care burden associated with an estimated cost of $50 billion in the United States. Therefore, it is imperative to prevent adverse events associated with polypharmacy, identify individuals who are at high risk of receiving inappropriate polypharmacy, and take steps toward deprescribing if possible. Criteria and Screening Tools Explicit criteria and tools have been created to support the deprescribing of inappropriate medications and to reduce the prevalence of polypharmacy in older adults. Mark Beers, MD, and colleagues initially developed the Beers Criteria in the US in 1991 to identify medications for which the potential harm outweighed the expected benefits for nursing home residents. Over time, the criteria have been revised and updated by the American Geriatrics Society (AGS), expanding to include all older adults in ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. The Beers Criteria is now used widely by clinicians, educators, researchers, health care administrators, and regulators, and although the list can be used internationally, it is specifically designed for use in the US. The updated 2023 Beers Criteria organizes potentially inappropriate medications (PIMs) by organ system and therapeutic category, outlines PIMs that should be used with caution, highlights clinically important drug-drug interactions, and describes medications that require renal dose adjustments. In addition to the Beers Criteria, the Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to Right Treatment (STOPP/START) criteria were developed in Ireland by O’Mahony et al in 2008 and are used predominantly in Europe. Data from an earlier study comparing the Beers Criteria with the STOPP/START criteria suggest that the STOPP/START criteria may be more sensitive because they account for therapeutic duplication and potential prescribing omissions, therefore identifying a significantly higher proportion of patients requiring hospitalization as a result of PIM-related adverse events when compared with the Beers Criteria. However, most of the studies conducted in which STOPP/START was applied were specific to an inpatient psychiatric setting compared with the wider application of the Beers Criteria in multiple settings outside the hospital and predominantly used in the US. Deprescribing and Reducing As individuals age, medications that were previously necessary, effective, and safe require reevaluation due to physiological and functional changes (ie, dementia, chronic comorbidities) that may shift the balance of benefits and harms. Additionally, there is increasing evidence that the benefits of many medications, particularly preventive medications, may be more harmful than beneficial with advancing age (eg, strict glycemic or blood pressure control). Therefore, it is imperative to reassess health care goals and priorities, as many older adults may want to shift their focus to comfort and maximizing quality of life. Deprescribing is a suggested intervention to reverse potentially iatrogenic harms of inappropriate polypharmacy and is defined as “the process of withdrawal of inappropriate medication, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes.” The Figure summarizes a potential approach to deprescribing. However, results of a meta-analysis showed limited evidence to support deprescribing as an intervention that reduced mortality in randomized studies. Findings from the same study also showed that mortality was significantly reduced when applying patient-specific interventions to deprescribing, suggesting that a more tailored, individual approach may be necessary for more class-specific deprescribing, such as with psychotropic and anxiolytic/hypnotic medications. Many studies have examined the importance of deprescribing certain psychotropic medications in older adults, particularly antipsychotics and anxiolytic/hypnotic medications. In particular, antipsychotic medications are frequently used to treat behavioral and psychological symptoms of dementia (BPSD), especially in long-term residential care settings. Antipsychotics carry an FDA black box warning for increased mortality in older adults and are listed on the Beers Criteria as a medication to be avoided. Data from many studies have shown that deprescribing antipsychotics in older adults with dementia did not result in worsening BPSD or adverse outcomes, suggesting that ongoing reevaluation and gradual dose reduction must be considered in these patient populations. Additionally, findings from another randomized control trial indicated that a systematic review of medications conducted in nursing homes reduced psychotropic drug prescriptions without worsening BPSD symptoms and improved level of functioning. Unfortunately, most studies focus on addressing inappropriate polypharmacy in older adults with dementia in long-term care facilities and have not extensively studied deprescribing in more outpatient-based settings to include the individual and their caregiver. Additionally, it is well known that benzodiazepines (BZDs) and the related hypnotic Z-drugs are harmful for older adults and can result in increased risk of falls, fractures, cognitive impairment, car crashes, and more. Unfortunately, deprescribing BZDs is more challenging than antipsychotics due to complex interactions among patients, physicians, and concerns about distressing but rarely fatal withdrawal syndrome.15 A recent review of deprescribing BZDs in older adults showed variable success rates in deprescribing, ranging from 27% to 80%, likely attributable to differing approaches that ranged from interventions targeting patient and/or caregivers and providing additional resources to the patient (eg, gradual dose reduction [GDR] with relaxation techniques, sleep hygiene, cognitive behavioral therapy). These interventions can be effective if the patient is motivated to cease taking the medication and does not have significant cognitive impairment, but prescribing interventions that include audits, algorithms, medication review, and supervised GDR may also be helpful additions for physicians to feel more comfortable deprescribing BZDs and related Z-drugs. For example, for patients in more advanced stages of dementia in which they exhibit neuropsychiatric and behavioral symptoms, antipsychotics may be needed to manage behavioral symptoms that have not responded to other interventions despite antipsychotics carrying an FDA black box warning for increased risk of mortality in patients older than 65 years with dementia. For some older adults, it may be impossible to avoid certain medications that may otherwise be contraindicated, and extensive discussion around goals of care, life expectancy, and potential drug-drug interactions and adverse effects are necessary with the patients and family/caregivers when assessing medication indications and their risks and benefits. (See “Strategies for Reducing Polypharmacy in Older Adults” in this article.) Concluding Thoughts Ultimately, more deprescribing intervention studies are needed given the complexity of interventions utilized and the variability of implementation of deprescribing in clinical practice across different health care settings. Deprescribing interventions will need to be tailored to individuals with more target-specific goals to be beneficial, but further studies are needed to determine if there are also unintended consequences to deprescribing. With the recent push discouraging the use of and making it difficult to prescribe antipsychotic and psychotropic medications in long-term care, culminating in the recently passed California law making the prescribers of psychotropic medications (except for antidepressants) legally responsible at the level of misdemeanor for prescribing without documented written consent, many older patients with severe mental illness or behavioral disturbances due to dementia may be left without necessary treatment for severe psychiatric symptoms, which will ultimately lead to greater suffering and caregiver burden. Clinicians should carefully weigh the risks and benefits of each prescribed medication for an older adult with neuropsychiatric diseases and periodically review all prescribed medications and over-the counter supplements and herbal remedies, and discontinue those that are unnecessary and potentially harmful. Note: This article originally appeared on Psychiatric Times .

Lauren Opladen remembers the agonizing wait all too well. At age 17, struggling with paralyzing depression after losing her brother to suicide and her father to amyotrophic lateral sclerosis, her teacher suggested she seek help. So, she did. But she had to spend 3 days inside an emergency department at the University of Rochester Medical Center in Rochester, New York, where the Comprehensive Psychiatric Emergency Program (CPEP) provides immediate care for youth and adults experiencing psychiatric emergencies. We were sleeping on a couch just waiting for all these services, when that's precious time wasted," Opladen said. Opladen made it through that dark period, and 5 years later, she is a registered nurse at the same hospital. Every day she walks past a new facility she wishes had existed during her troubled teenage years: An urgent care center for children and adolescents experiencing mental health crises. Brighter Days Pediatric Mental Health Urgent Care Center, Rochester, New York, opened in July as a walk-in clinic offering rapid assessment, crisis intervention, and short-term stabilization, provides referrals to counseling or psychiatric care. Children and adolescents at immediate risk of harming themselves or others, or who need inpatient care, are sent to CPEP or another emergency department in the area. Similar walk-in facilities linking youth to longer-term services are popping up in nearly a dozen states, including New York, Ohio, Massachusetts, and Wisconsin. The emerging model of care may offer a crucial bridge between traditional outpatient services and emergency room (ER) visits for some young people experiencing mental health crises. "We've seen a significant increase in the number of children and adolescents presenting to emergency departments with mental health concerns," said Michael A. Scharf, MD, chief of the Division of Child and Adolescent Psychiatry at the University of Rochester Medical Center, who oversees operations at Brighter Days. "These urgent care centers provide a more appropriate setting for many of these cases, offering specialized care without the often overwhelming environment of an ER." The urgency of addressing youth behavioral health has become increasingly apparent. The most recent data from the US Centers for Disease Control and Prevention showed that over a 6-month period in 2020, during the early months of the COVID-19 pandemic , visits to the emergency department for mental health problems spiked 24% among children aged 5-11 years and 31% among 12-17-year-olds compared with the same period in 2019. Between March 2021 and February 2022, such emergency visits rose by 22% for teen girls, while falling by 15% for boys ages 5-12 years and 9% for older boys. Most visits occur during the school year. But staffing shortages and limited physical space are taxing the capacity of the healthcare system to screen, diagnose, and manage these patients, according to a 2023 report published in Pediatrics. Urgent Care: A Misnomer? Some in the mental health community said the label "urgent" in these centers' titles is misleading. Brighter Days and similar facilities do not conduct involuntary holds, administer medication, or handle serious cases like psychotic episodes. David Mathison, MD, senior vice president of clinic operations at PM Pediatrics, a chain of pediatric urgent care clinics in Maryland, said patients and their families may mistakenly believe the centers will address mental health problems quickly. "It's really not urgent behavioral health. It's really just another access point to get behavioral health," Mathison said. "Crises in pediatrics are so much more complex" than physical injuries or acute infections, which are the bread and butter of urgent care centers. "An urgent care center almost implies you're going to come in for a solution to a simple problem, and it's going to be done relatively quickly on demand, and it's just not what the behavioral health centers do," he said. Mathison, who also serves on the executive committee for the section on urgent care at the American Academy of Pediatrics, likened the centers to in-person versions of crisis center hotlines, which offer virtual counseling and talk therapy and may refer individuals to specialists who can provide clinical care over the long term. Instead, Brighter Days and other centers provide crisis de-escalation for individuals experiencing an exacerbation of a diagnosed mental illness, such a manic episode from bipolar disorder. "Most places aren't just going to change their therapy without either contacting their psychiatrist or having psychiatrists on staff," Mathison said. Other challenges at Brighter Days and similar centers include staffing with appropriately trained mental health professionals, given the nationwide shortage of child and adolescent psychiatrists, Scharf said. The number of child and adolescent psychiatrists per 100,000 children varies significantly across states. Nationally, the average stands at 14 psychiatrists per 100,000 children, but ranges from as low as 4 to 65, according to the American Academy of Child & Adolescent Psychiatry. For now, Scharf said, patients who visit Brighter Days are billed as if they are having a routine pediatric office visit as opposed to a pricier trip to the emergency department. And the center accepts all individuals, regardless of their insurance status. Opladen said the urgent care center represents a significant improvement over her experience at the emergency department's psychiatric triage. "I saw how awful it was and just the environment," she said. "The first thing I thought was, what do I need to do to get out of here?" She said the pediatric mental health urgent care centers are "the complete opposite." Like Brighter Days, these centers are designed to look more like a pediatrician's office, with bright welcoming colors and games and toys. "It's separated from everything else. There's a welcome, relaxed space," she said. "The welcoming feel is just a whole different environment, and that's really how it should be." Note: This article originally appeared on Medscape .

It is no secret that the accelerating climate change increasingly threatens patients' mental health and psychosocial well-being, leading to psychologic distress, anxiety, depression, grief, and suicidal behavior. This relationship is evidenced by the emergence of new terms such as "eco-anxiety." During the recent Days of Neuroscience, Psychiatry, Neurology, a session brought together Professor Martin Beniston, a climatologist from the University of Geneva, Geneva, Switzerland, and former director of the Swiss Environmental Science Institute, and Professor Philippe Conus, a psychiatrist at the University Hospital of Lausanne in Lausanne, Switzerland. Beniston has significantly contributed to understanding the effects of climate change and developing adaptation strategies. Conus conducts research aimed at the early detection of mental disorders related to climate change to propose appropriate interventions. The latter provided advice on coping with widespread eco-anxiety, especially within the younger generation. Global Temperatures Rise "Since the industrial era, there has been a continuous rise in global temperatures, just over 1 °C in the span of a century, with an even more pronounced increase in the European territory," said Beniston. He supported his statements with an illustrative composite animation created by National Aeronautics and Space Administration in 2022 that showed the evolution of Earth's temperature year after year. "But more than temperatures, it is the climate consequences that will have an impact on mental health," he said. The effects can be direct when heat waves, extreme cold, and natural disasters lead to physical and psychologic vulnerability, as seen with repeated floods in northern France this past winter. The effects also can be indirect, however, as pollution, invasive species, and new contamination pathways are capable of amplifying or generating new infectious and other diseases. "What is worrying," he said, "is that we are already witnessing events today that the Intergovernmental Panel on Climate Change predicted for 2040/2050 and beyond." Impact Varies Among Populations "While the effect of climate change on mental health is now evident, the impact is not the same for everyone, with some groups disproportionately affected, based on factors such as socioeconomic status, gender, and age," said Conus. In this regard, patients with mental illness are particularly vulnerable. For example, the northwest part of North America experienced an unprecedented heat wave in 2021 that was characterized by high temperatures and reduced air quality. The event resulted in approximately 740 excess deaths in the province of British Columbia. During the eight hottest days in the region, 134 patients with schizophrenia died, which was triple the average number of deaths during the same period between 2006 and 2020. Nevertheless, studies focusing not on vulnerable patients but on the general population also show a link between climate change and mental health. One study coupled meteorologic and climatic data with reported mental health difficulties in two million randomly sampled American residents between 2002 and 2012. It revealed that a shift from average temperatures of 25 °C to 30 °C was associated with a 0.5% increase in the prevalence of mental health problems, equivalent to 2 million additional patients for the United States, "which would still amount to 320,000 individuals in France," said Conus. Moreover, a 1 °C average warming over 5 years was linked to a 2% increase in the prevalence of mental health problems. This increase translates to an additional eight million patients for the United States and an additional 1.2 million patients for France. Psychiatric Consequences From a strictly psychiatric perspective, "the impacts of climate change can be classified into three categories," said Conus. First, there are direct impacts, such as natural disasters that cause significant destruction like fires or floods. "We observe an increased incidence of depressive states, posttraumatic disorders, and even suicides when individuals are directly affected, with a gradual effect over time." Indeed, a study showed that Hurricane Katrina led to 40 times more psychologic disorders than somatic ones. The second category includes gradual impacts that affect individuals, such as farmers who tend the land for their work. "For them, this slow change resulting in periods of drought or rising waters will lead to income and activity losses, ultimately causing depression and suicides. This progression of disorders has been well demonstrated in the American Midwest with a twofold increase in drought episodes and a rise in the number of suicides." Finally, there are indirect impacts, which primarily are observed in Western societies. "It is eco-anxiety or solastalgia, this nostalgia for the planet as we once knew it and sadness for a new ecosystem in which we are deprived," said Conus. A New Condition Of the two terms, eco-anxiety has been predominantly used to describe the sense of fatalism toward climate change. "It mainly manifests as fear, which can even be paralyzing, along with sadness and anger." One of the main contributors to this anxiety is the inaction or inadequate action by governments in facing the environmental crisis. A study published in Lancet in 2021 showed that out of 10,000 young people surveyed in 10 countries (ie, Australia, Brazil, Finland, France, India, Nigeria, the Philippines, Portugal, the United Kingdom, and the United States), 60% reported feeling "very worried" or "extremely worried" and associated negative emotions (eg, sadness, fear, anxiety, anger, and helplessness) with climate change. Reconnecting With Nature Are there keys to managing eco-anxiety? "First, one must acknowledge the reality of the concern" and "share one's own experience," said Conus. Among the practical advice to give to patients, he suggests not staying alone with one's feelings and sharing them with others. "It is also essential not to spend too much time in front of screens with information but to "give oneself bubbles of disconnection," he said. He also recommended staying connected with nature, which is known for its benefits, and "developing resources to experience positive and negative emotions." Another solution proposed is to act, thereby regain a measure of control over matters, he said. "Each person can engage at his or her scale, according to his or her means and limits." Patients can choose products from environmentally friendly agriculture, reduce red meat consumption, prefer trains over planes, and embrace simple pleasures. For citizens, acting includes voting, engaging in associations, speaking out in debates, and exerting pressure on political representatives. Healthcare professionals can take actions in medical clinics or hospitals and join an association. Note: This article originally appeared on Medscape .

PSYCHIATRIC VIEWS ON THE DAILY NEWS That psychiatrist is me and that reunion is tomorrow evening. As I think about it and recall prior high school reunions I attended (5, 20, and 50, I think), I conclude that it is especially important for psychiatrists to attend, but a little tricky. You Were Always a Psychiatrist Like most high schoolers, our experiences in high school seemed to run the gamut from negative to positive. No matter what, though, a late reunion provides an opportunity to reflect back on that time in order to more completely put one’s life in perspective and meaning, as death and dying is more clearly on the visible horizon. Others may share their high school experience of you and vice versa, and that adds to our personal pictures. At my 50th reunion a decade ago, I was asked how I knew I was going to be a psychiatrist back then. I think I answered something like: my Jewish mother wanted me to be a doctor but I did not like biology, but did love reading Freud, so psychiatry fulfilled all. Interestingly enough, I received 2 special 1-time high school designations: Most Modest and Most Accident Prone, the latter of which I discussed in our last column. I think I do not deserve those designations anymore, but did receive another 1-time designation as a psychiatrist: Hero of Public Psychiatry (APA annual meeting, 2002). Are there any connections between these designations, say perhaps the recklessness of being accident-prone and supposedly heroic? Now I have been retired 12 years, but am still a psychiatrist, but a different kind of one, mainly a writer and presenter. You Learn About Normal Life Development Inevitably, some classmates will meet expectations or even exceed them, and others not. Life circumstances can provide unexpected influences that open or close opportunities. Moreover, what caused success in high school may not do so as much in later life. We in psychiatry generally do not see ordinary development over a lifetime other than family and long-term friends. That can leave us with a distorted view of humanity. Reunions help rectify that, especially greased with a little alcohol, and the 60th will most likely be the last one. The Image and Stigma of Psychiatry Back when I was in high school, the stigma against psychiatric patients and psychiatrists was high. Fortunately, that has gradually dissipated over 60 years. In such reunions, we are the bearer of the fantasies about psychiatrists. We have the opportunity to look more or less normal, including not appearing like we are trying to analyze everyone, even if we might be doing so a little bit! My analysis of the actual reunion tomorrow will likely appear in an upcoming column. My prescription to the rest of us: go to your school reunions whenever you can. Note: This article originally appeared on Psychiatric Times .

Keypoint: NIH-funded study of conduct disorder identifies new brain areas associated with the disorder, offering future directions for research efforts and clinical practice. A neuroimaging study of young people who exhibit a persistent pattern of disruptive, aggressive, and antisocial behavior, known as conduct disorder, has revealed extensive changes in brain structure. The most pronounced difference was a smaller area of the brain’s outer layer, known as the cerebral cortex, which is critical for many aspects of behavior, cognition, and emotion. The study, co-authored by researchers at the National Institutes of Health (NIH), is published in The Lancet Psychiatry. “Conduct disorder has among the highest burden of any mental disorder in youth. However, it remains understudied and undertreated. Understanding brain differences associated with the disorder takes us one step closer to developing more effective approaches to diagnosis and treatment, with the ultimate aim of improving long-term outcomes for children and their families,” said co-author Daniel Pine, M.D., Chief of the Section on Development and Affective Neuroscience in NIH’s National Institute of Mental Health. “Critical next steps are to follow children over time to determine if differences in brain structure seen in this study are a cause of conduct disorder or a long-term consequence of living with the disorder.” A collaborative group of researchers examined standardized MRI data from youth ages 7 to 21 who had participated in 15 studies from around the world. Analyses compared the surface area and thickness of the cerebral cortex and the volume of deeper subcortical brain regions between 1,185 youth diagnosed with conduct disorder and 1,253 youth without the disorder. Additional analyses compared the cortical and subcortical brain measures between boys and girls, age of symptom onset (childhood vs. adolescence), and level of empathy and other prosocial traits (high vs. low). Youth with conduct disorder had lower total surface area across the cortex and in 26 of 34 individual regions, two of which showed significant changes in cortical thickness. Youth with conduct disorder also had lower volume in several subcortical brain regions, including the amygdala, hippocampus, and thalamus, which play a central role in regulating behaviors that are often challenging for people with the disorder. Although some of these brain regions, like the prefrontal cortex and amygdala, had been linked to conduct disorder in previous studies, other regions were implicated in the disorder for the first time. The associations with brain structure did not differ between boys and girls and were seen across conduct disorder subgroups based on age of onset and level of prosocial traits. Youth who exhibited signs of a more severe form of the disorder, indicated by a low level of empathy, guilt, and remorse, showed the greatest number of brain changes. These findings from the largest, most diverse, and most robust study of conduct disorder to date are consistent with a growing body of evidence that the disorder is related to the structure of the brain. The study also provides novel evidence that brain changes are more widespread than previously shown, spanning all four lobes and both cortical and subcortical regions. These findings offer new avenues for investigating potential causal links between differences in brain structure and symptoms of conduct disorder and for targeting brain regions as part of clinical efforts to improve diagnosis and treatment. Note: This article originally appeared on NIMH .

Does psychiatry’s future lean towards online practice? Telepsychiatry is a form of telemedicine that uses telephone or video conferencing tools to provide psychiatric services . As with in-person psychiatric treatment, telepsychiatry providers can evaluate and diagnose, provide therapy, and prescribe medication. On the one hand, I fully agree with Dr Varas that something is lost when we are not meeting in the same room with our patients. As I stated in my article, however, I think that telepsychiatry will increasingly be the way of the future, especially with younger generations of patients and therapists, along with continued advances in technology. Dr. Reddy believes that telepsych allows patients that are in remote areas of the country of state the access to quality doctors. People feel more comfortable taking about sensitive issues in their own environment. It eliminates the white coat syndrome. The no show rate is dramatically improved as it is much more flexible than commuting at least 30 minutes to 1 hour for an appointment, then seeing the doctor then being stuck in traffic. In this fast paced word, we don't have much time. The advantage of telepsych is we don't have to do a physical examination on patients, which is unlike many other fields who are transitioning into telehealth. The Way to Improve Mental Health in Missouri and Kansas City I see patients from 7 hours away which would have been impossible with the benefits of telepsychiatry. I can see patients all over Missouri and Kansas City which is a major advantage as they are often burned out by their local providers and want a clean state. Now a days it's common to psychiatrists to practice in multiple states to reach more patients. I hope to expand with more Midwest states in the near especially with the patient population i see which is highly vulnerable. Dr Vilash Reddy is the owner of One Life Psychiatry. As a child/adult/addiction psychiatrist, he has a holistic approach mental health, through the use of medication, therapy, and alternative remedies. His main focus he believes is vitally important is to educate and empower patients that are struggling with mental illness. He places a strong emphasis on understanding the patient way before prescribing random medicines which why he often the 2nd, 3rd, etc opinion.

The commercialization of cannabis that followed its legalization for nonmedical use was associated with an increase in hospitalizations for cannabis-related health problems, including cannabis-induced psychosis, according to new research. In a repeated cross-sectional analysis that included some 26.9 million individuals, researchers found that the rate of hospitalizations due to cannabis increased 1.62 times between 2015 and 2021. The rate of hospitalizations increased most precipitously after commercialization, including a 40% increase in hospitalizations for cannabis-induced psychosis. Decline With Legalization Canada has a universal healthcare system, and the researchers accessed health administrative databases that recorded all acute hospitalizations for patients aged 15 to 105 years in the four most populous provinces: Ontario, Quebec, Alberta, and British Columbia. They compared changes in rates of hospitalizations due to cannabis over the following three time periods: prelegalization (January 2015 to September 2018), legalization with product and store restrictions (October 2018 to February 2020), and commercialization (March 2020 to March 2021). There were 105,203 hospitalizations due to cannabis during the study period. Most (65.8%) were in males, and one third were in adolescents and young adults aged 15 to 24 years. The age- and sex-standardized rate of hospitalizations due to cannabis increased 1.62 times: from 3.99 per 100,000 individuals in January 2015 to 6.46 per 100,000 individuals in March 2021. The largest relative increase in hospitalizations was for cannabis-induced psychosis, which rose 40% during the commercialization period, compared with the prelegalization period (rate ratio, 1.40). The period of legalization with restrictions was associated with a gradual monthly decrease of −0.06 in hospitalizations due to cannabis per 100,000 individuals. During the commercialization period, which coincided with the COVID-19 pandemic, there was an immediate increase of 0.83 hospitalizations due to cannabis per 100,000 individuals. 'Legalization, Not Commercialization' Legalizing cannabis removes an important reason for incarceration, said Myran. "That is an important public health gain. There’s very compelling data that making cannabis illegal ended up giving a lot of young people criminal records, and in Canada, it’s disproportionately in Black and indigenous youth. You get a criminal record, and it has major social harms." Before cannabis was legalized in Canada, it became easier to obtain. Gray market stores selling cannabis were no longer being closed by the police. In the lead-up to legalization, cannabis use increased. But once legalization with restrictions was instituted, hospitalizations for cannabis use declined, said Myran. "Legalization in Canada has taken a graduated rollout, so you have an initial legalization with restrictions, where the government would only allow the sale of dried cannabis flower, there were almost no stores, and you actually see these rates decline. But later on, when the market matures and you have a vast amount of stores, new products like vape pens and edibles and concentrates and cannabis-infused beverages, and which happens to overlap with the COVID-19 pandemic, you see a jump in cannabis hospitalizations," he said. Cannabis use can be very harmful for some individuals. It is well known that cannabis use in adolescents and young adults is associated with the development of psychosis, said Myran. "There are individuals who are predisposed to develop psychosis, and cannabis seems to bring on psychotic episodes in those who are vulnerable. In one study, 26% of people who presented to the emergency department with an episode of cannabis-induced psychosis went on to develop schizophrenia within the next 3 years," he said. We need legalization, not commercialization, Myran said. Promoting Cannabis Misuse? Increased commercialization is increasing the availability of cannabis, hence problems with abuse and overuse will occur, he added. Sherry did not participate in the research. "We know from the alcohol literature, the tobacco literature, and increasingly from the cannabis literature that with the increase of the physical availability of cannabis outlets, you also increase potential for abuse of cannabis," he said. While claims that sales of cannabis products provide a source of revenue for governments may be true, the main source of that revenue is the regular user, Sherry said. "The dirty secret in the legalization and commercialization of cannabis is that most of the revenue comes from frequent or addicted customers. Someone who buys 1 gram and uses it recreationally in a month is not a good customer. The good customers are frequent and addicted individuals who are going to smoke 5 grams of cannabis a day." Commercialization results in more direct appeals to addiction-prone people, Sherry added. "For instance, in Nova Scotia, we promote cannabis as a way to relax and enhance your experience. If you are addiction-prone, that messaging, and the increased physical availability of cannabis with commercialization, means that we are going to see more cannabis problems. So, if you add more cannabis outlets, as you heavily commercialize cannabis products, you add more cannabis problems to our society." Cannabis is not a benign substance, Sherry emphasized. Increasing awareness of the associated harms, as has occurred with tobacco, would be a better way of marketing cannabis, he suggested. "Rather than the current relaxed and permissive attitude, we need to switch to one of grudging tolerance, recognizing that cannabis is going to be part of our landscape, that some people are going to use it and some are going to misuse it, and that we need to discourage the consumption of cannabis as a public health problem," said Sherry. The study was supported by a grant from the Canadian Centre on Substance Use and Addiction and fellowships from the Canadian Institutes of Health Research and the University of Ottawa Department of Family Medicine. Myran reported grants from Canadian Institutes of Health Research during the conduct of the study. Sherry reported no relevant financial relationships. Related Topics: One Life Psychiatry

HELSINKI — Nightmares in middle age are linked to a significantly increased risk for subsequent dementia, new research suggested. However, one expert is skeptical that this is the case. Investigators found that middle-aged adults who reported having weekly distressing dreams at baseline had a fourfold increased risk of developing dementia compared with their counterparts who had no nightmares. "It is likely that distressing dreams are either a causal risk factor for dementia or one of the earliest signs of it," said study investigator Abidemi Otaiku, MD, Imperial College London, London, England. The findings were presented here at the Congress of the European Academy of Neurology (EAN) 2024 annual meeting. Robust Link As previously reported by Medscape Medical News , Otaiku and colleagues found healthy middle-aged adults from the MIDUS study who had bad dreams at least once a week were four times more likely to experience cognitive decline over the following decade than those without distressing dreams. In addition, older adults who reported nightmares had a twofold increased risk for all-cause dementia. The current study furthers the previous research by analyzing a subset of study participants who had genetic data available that was based on blood tests, saliva samples, and family history to determine if these had any impact on the previous findings. "We found that after controlling for genetic factors, the association between distressing dreams and both cognitive decline and dementia remained robust," Otaiku told Medscape Medical News. "We also found that there was no significant relationship between distressing dream frequency and genetic factors in either age group." Given that there's no cure for Alzheimer's disease (AD) or other dementia types, "it's important that we identify people at the early stage before they develop symptoms, so they can benefit from disease-modifying drugs, when available, and preventive strategies," Otaiku added. Future studies are needed to determine whether treating distressing dreams could help slow cognitive decline and/or prevent dementia, he said. In response to a question from the audience about rapid eye movement (REM) sleep behavior disorder following his talk, Otaiku said he did not have data on this but added that he believes it's unlikely that it explains the association between bad dreams and dementia. He pointed out that REM sleep behavior disorder is very rare, affecting < 0.05% of the population of those aged 50 years and older. Second, he said there has been one study, to his knowledge, looking at REM sleep behavior disorder and all-cause dementia, which showed the disorder did not predict all-cause dementia, whereas nightmares were predictive. Finally, said Otaiku, there are data on diagnosed sleep disorders from one of his studies, which showed that even when all participants with a diagnosed sleep disorder were excluded, the relationship between nightmares and dementia risk remained robust. "Therefore, it seems unlikely that REM sleep behavior disorder explained the association," he said. Otaiku noted his team also adjusted for neuropsychiatric disorders such as anxiety, depression, and stress, and still the link between nightmares and dementia risk remained robust. Similarly, they adjusted for medication use, including antidepressants, benzodiazepines, and hypnotics, and found this also didn't explain the increased dementia risk. He noted that the study had an outcome of all-cause dementia and that his team didn't have access to data on specific dementia diagnoses. "Presumably, Lewy body dementia would be one of the strongest associations, but given that this makes up less than 5% of diagnoses in the community, it's likely that the effects may apply to Alzheimer's disease too, and previous studies have shown that nightmares are more common in Alzheimer's disease at certain stages," he concluded. A More Likely Culprit? Commenting on the research for Medscape Medical News , Sebastiaan Engelborghs, MD, PhD, professor and chair of neurology, Vrije Universiteit Brussel, Brussels, Belgium, and co-chair of the EAN Scientific Panel on Dementia and Cognitive Disorders, said the findings are not novel. "I suspect the subjects with 'distressing dreams' to have rapid eye movement (REM) sleep behavior disorder. This can only be ruled out by a sleep exam, which was not performed — to my knowledge — in this study." "It is well-known that REM sleep behavior disorder may precede dementia by many years. One of the key symptoms of REM sleep behavior disorder are nightmares, or 'distressing dreams'…and this is why we always ask about sleep and nightmares during consultations in the memory clinic," Engelborghs added. "That is also why we follow up on cognitively healthy subjects who show up with nightmares, suggestive of REM sleep behavior disorder, as we do know that they are at increased risk of developing dementia, and we disclose this to them," he added. Speaking to Otaiku's suggestion that future trials could assess whether treating distressing dreams might slow the onset of, or prevent, dementia, Engelborghs said that his patients with REM sleep behavior disorder are treated with specific medications "as the symptoms can be very distressing." However, he noted treating sleep symptoms does not reduce dementia risk. Disordered sleep is often the first, early manifestation of neurodegeneration that is the cause of future dementia, he said. Note: This article originally appeared on Medscape .

Keypoint: This randomized, placebo-controlled, phase 3 clinical trial showed that a 14-day treatment course of oral zuranolone 50 mg/day in MDD led to significantly greater improvements in depressive symptoms when compared with placebo. 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. Zuranolone is a positive allosteric modulator of the synaptic and extrasynaptic γ-aminobutyric acid type A (GABAA) receptor. It is postulated to upregulate GABAA receptor expression and enhance the inhibitory GABAergic signaling, thereby rapidly restoring network balance within the brain areas that are dysregulated in depression. This phase 3 study evaluated the efficacy, safety, and tolerability of zuranolone 50 mg/day in the treatment of major depressive disorder (MDD) among adults. Study Objectives To investigate the efficacy and safety of a 14-day treatment course of once-daily zuranolone 50 mg, an investigational oral positive allosteric modulator of the GABAA receptor, for the treatment of MDD. Methodology This study was a randomized, double-blind, placebo-controlled phase 3 clinical trial conducted from May 2020 to April 2021 at 39 sites across the United States. The study participants were otherwise healthy 18- to 64-year-old adults with MDD and a Hamilton Depression Rating Scale (HAM-D) score of greater than or equal to 24 at day 1 of treatment. The participants were randomly assigned in a 1:1 ratio to zuranolone or control groups. The participants self-administered oral zuranolone 50 mg or placebo with fat-containing food for 14 days, with a controlled follow-up period of 28 days for a total study period of 42 days. The primary outcome of this study was the least square means (LSM) change from baseline in HAM-D score at day 15. Study Results A total of 543 individuals were enrolled in the study, with 271 assigned to zuranolone and 272 assigned to placebo. The baseline characteristics for each group were largely similar. Both groups had similar days since the start of current depressive episode (468.2 for zuranolone vs 481.0 for placebo), number of depressive episodes experienced (5.3 for both groups), and severity of depressive symptoms as assessed by HAM-D (26.8 for zuranolone vs 26.9 for placebo). Participants in both groups had similar prior psychotropic use, with one difference being that no participants in the zuranolone group had been prescribed benzodiazepine derivatives in the 6 months prior to screening vs 5 participants in the placebo group. The primary end point of LSM change from baseline in the HAM-D scores at day 15 was significantly better in the zuranolone group compared with the placebo group (LSM change, –14.1 vs –12.3 [SE = 0.5]; P = .01; Cohen d = 0.23). The LMS change in the Clinical Global Impressions-Severity (CGI-S) score at day 15 was numerically greater in the zuranolone group vs the placebo group, although this result did not reach statistical significance (–1.8 [SE = 0.1] vs –1.6 [SE = 0.1]; P = .12). The LMS changes in the HAM-D scores from baseline were statistically significant in the zuranolone group at days 3 (–9.8 [SE = 0.4] vs –6.8 [SE = 0.4]; P < .001; Cohen d = 0.49), 8 (–12.0 [SE = 0.5] vs –9.5 [SE = 0.5]; P < .001; Cohen d = 0.38), and 12 (−13.7 [SE = 0.5] vs −11.2 [SE = 0.5]; P < .001; Cohen d = 0.32) when compared with the placebo group. Although the LMS changes in the HAM-D scores from baseline showed numerical superiority in the zuranolone group when compared with the placebo group at days 21 (−13.3 [SE =0.5] vs −12.1 [SE = 0.5]; P = .09), 28 (−12.6 [SE = 0.5] vs −11.6 [SE = 0.5]; P = .18), 35 (−13.0 [SE = 0.6] vs −12.3 [SE = 0.6]; P = .37), and 42 (−13.5 [SE = 0.6] vs −12.6 [SE = 0.6]; P = .23), these results did not reach statistical significance. The investigators identified that a greater proportion of individuals in the zuranolone group achieved HAM-D response (≥ 50% reduction in score from baseline) at day 3 (29.3% vs 16.3%; odds ratio [OR] = 2.1; P < .001). Additionally, a greater proportion of individuals in the zuranolone group achieved HAM-D response at day 15 (56.0% vs 47.0%; OR = 1.4; P =.06) and at day 42 (52.9% vs 45.9%; OR = 1.4; P = .09), but these results did not reach statistical significance. The investigators found improvements in the depressive symptoms at day 15 among the zuranolone group when compared with the placebo group, as measured by the change from baseline in the Montgomery-Åsberg Depression Rating Scale scores (LSM change, −17.5 [SE = 0.8] vs −15.1 [SE = 0.8]; P = .02). The investigators noted that the remission rates for depression were numerically greater in the zuranolone group at days 15 (29.8% vs 27.1%; OR = 1.1; P = .55) and 42 (30.8% vs 29.6%; OR = 1.1; P = .68), but these results were not statistically significant. A significantly greater proportion of participants in the zuranolone group had improvements in the CGI-Improvement ratings of “much improved” or “very much improved” at day 15 when compared with the placebo group (62.1% vs 51.0%). Greater improvements in anxiety symptoms , as assessed by a change in Hamilton Anxiety Rating Scale score at day 15, were noted in the zuranolone group when compared with placebo group (LSM change, –10.4 [SE = 0.4] vs –9.1 [SE = 0.4]; P = .02). Safety Outcomes Treatment-emergent adverse events (TEAEs) occurred in 60.1% of participants receiving zuranolone vs 44.6% of the participants receiving placebo. Most TEAEs were rated as being mild or moderate (95.0% for zuranolone vs 97.5% for placebo). The most common TEAEs were somnolence (15.3% for zuranolone vs 3.0% for placebo), dizziness (13.8% for zuranolone vs 2.2% for placebo), headache (10.8% for zuranolone vs 7.8% for placebo), sedation (7.5% for zuranolone vs 0.4% for placebo), and diarrhea (3.0% for zuranolone vs 5.2% for placebo). Dose reduction due to TEAEs was required in 23 participants in the zuranolone group and 1 in the placebo group. The most common reasons for dose reduction were dizziness and somnolence with the zuranolone group and fatigue in the placebo group. A total of 9 participants in the zuranolone group discontinued treatment due to TEAEs vs 4 in the placebo group. The most common reasons for treatment discontinuation were dizziness and sedation in the zuranolone group and sedation and somnolence in the placebo group. There were no deaths, loss of consciousness, weight gain, sexual dysfunction, or euphoria noted in the study participants. A total of 0.7% of the participants in each group experienced serious AEs. Conclusions Zuranolone 50 mg/day led to significant improvement in depressive symptoms at day 15 when compared with placebo. The observed effect was rapid, with greater improvement in the HAM-D and CGI-S being observed for zuranolone by day. Improvements in depression and anxiety symptoms were sustained through day 42 for participants taking zuranolone. Overall, zuranolone was well tolerated when compared with placebo. Practical Applications Zuranolone offers a novel mechanism of action for the treatment of MDD. This study included individuals with severe depressive episodes of long duration. Zuranolone was given with other antidepressants, which suggests it could be used in combination with antidepressants to harness several psychopharmacologic mechanisms simultaneously. Bottom Line This randomized, placebo-controlled, phase 3 clinical trial showed that a 14-day treatment course of oral zuranolone 50 mg/day in MDD led to significantly greater improvements in depressive symptoms when compared with placebo at day 15, with a rapid onset of effectiveness noted (day 3). The medication was generally well tolerated, with no new safety concerns when compared with previous studies of zuranolone at lower doses. Note: This article originally appeared on Psychiatric Times .

Keypoint: Research shows an increased risk for suicidal thoughts, suicide attempts, and even death by suicide following brain injury. europsychiatric disorders regularly occur following brain injury and are often diagnosed within a year of the injury. Mood disorders, particularly major depressive disorder (MDD), are the most frequently diagnosed DSM-5 psychiatric disorders after brain injury. Mood disorders can develop with or without a preinjury history of psychiatric disorder, and can increase risk for suicidal thoughts. MDD Following Brain Injury Prospective studies using structured clinical interviews report rates of depression between 13.9% and 23.2% within the first year of injury for mild brain injury. Reported rates of MDD for a wider range of injury severity are higher, ranging from 15.3% to 33%. Risk factors for MDD include preinjury depression, focal lateral lesions and left anterior lesions, and psychosocial stressors including social isolation and maladaptive coping. MDD following brain injury was associated with comorbid anxiety and self-reported lower quality of life at 1 year after the injury. Suicide Risk and Suicidality Studies report an increased risk for suicidal thoughts, suicide attempts, and even death by suicide following brain injury. Makelprang followed a cohort of adults with traumatic brain injury (TBI) for 1 year after discharge from the hospital, and found that 25% of the sample reported suicidal ideation within the first year of injury. The strongest predictors of suicidal ideation after brain injury included prior history of suicide attempt, neuropsychiatric diagnosis (depression, bipolar disorder), and less than a high school education. Simpson and Tate reported a lifetime prevalence rate of 26.2% for suicide attempt in an outpatient sample with TBI. They also examined the clinical features of suicide attempts after TBI in an outpatient cohort followed over a 24-month period. Their data set included 43 patients who made a total of 80 suicide attempts; 30% of the attempts were preinjury and 70% postinjury. Over 55% of the sample made a single attempt, 25.6% made 2 attempts, and 18.6% made 3 or more attempts. Of those that made 3 or more attempts, the repeat attempts occurred within 13 months of the index attempt, and over one third making multiple attempts used the same method. Excessive alcohol intake within the prior 24 hours, psychological distress brought on by antecedent stressors (arguments, loss of a significant relationship, negative feedback, etc), and hopelessness combined with high suicidal ideation, were associated with suicide attempt after TBI. Treatment and Prevention Prevention and treatment interventions for suicidal ideation and attempt can include pharmacological and psychosocial approaches, substance misuse treatment, environmental modifications, and when necessary, emergency intervention.10,11 Given the multiple and complex challenges associated with this population, practitioners are encouraged to adapt and individualize treatment and prevention practices.11 In terms of pharmacological intervention, SSRIs, namely sertraline, have been found to be effective an first line treatment for depression.12 In addition to treating depressive symptoms, SSRIs may also improve other frequently reported TBI symptoms, such as irritability, aggression and poor impulse control. When prescribing medications following TBI, a conservative, approach to dosing (ie, “low and slow”) is recommended as individuals with TBI may be sensitive and susceptible to medication adverse effects.13 Psychosocial interventions, such as support groups, strengthening family relationships, and involving patients in social skills training have been effective in decreasing feelings of loneliness and isolation.10 In a controlled trial, Simpson et al randomized a group of adults with severe TBI and severe hopelessness or suicidal ideation to either an intervention group (n=8) or a wait list control group (n=9).14 The participants in the intervention group received a 20-hour, manualized cognitive behavior therapy program. Interventions assisted participants to live a positive lifestyle by promoting expression of thoughts and feelings, reframing/reappraising disturbing situations, acquire adaptive coping skills (ie, problem-solving, asking for help, etc), and promoting posttraumatic growth by making meaning of the brain injury. The treatment group demonstrated a significant reduction in hopelessness, and this effect was maintained at 3-month follow-up for 75% of participants. Given that substance abuse, particularly alcohol abuse, is a risk factor for suicide attempt, substance abuse treatment can be an important component in a suicide prevention plan.9,10 Environmental modifications, such as restricting access to sharps, guns, toxic chemicals, and other means of self-harm, has been shown to be effective in reducing suicide.10 Use of “No Harm Contracts” could be an appropriate intervention for patients with brain injury. A no harm contract is an intervention intended to prevent self-harm.15 It is a written agreement between a clinician and a patient (ie, person receiving psychotherapy or mental health services) whereby the patient promises not to harm themself. Reviewers of the literature on the efficacy of No Harm Contracts argue a lack of quantitative evidence to support the use of such contracts.16 Conceptual and ethical issues related to the use of No Harm Contracts include: Potential for coercion from the clinician for their own protection (ie, legal protection) Patients who agree to such contracts remain at high risk for suicide Contracts can falsely reassure clinicians which may result in decreased attention and concern about a patient’s suicide risk A significant percentage of patients that signed a contract either attempted or completed suicide However, alternatives to No Harm Contracts have shown limited or questionable utility. Some clinicians believe that the absence of extensive research concerning the efficacy of contracts in the prevention of suicide should not be used to conclude that contracts have no therapeutic benefit or usefulness in treating suicidal patients. Some potential benefits could include: A patient’s willingness to engage in a contract can be a useful tool in assessing suicidality A contract allows the clinician an opportunity to express genuine concern and commitment to the patient which may bolster the therapeutic relationship Emphasizing a shared common goal may increase the connection between therapist and patient and provide a calming effect The contract may also provide an opportunity for the patient to safely explore self-destructive feelings and meanings of life and death. Like all therapeutic interventions and techniques, those that address suicidality must be tailored to each patient. Note: This article originally appeared on Medscape .