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PSYCHIATRIC VIEWS ON THE DAILY NEWS In yesterday’s column, I mentioned feeling dazed and confused after the Presidential debate. Other colleagues have expressed some similar reactions: “a physical gut punch,” “devastatingly unbelievable,” “the stuff of nightmares” from one side, with more positive emotional reactions from the other side. Thankfully, Al Simon, a new friend, came to my rescue. A week or 2 before, he strongly recommended I see “Inside Out 2,” thinking I would be interested in it as a psychiatrist and that he would like to know my reaction. One thing led to another, and we went yesterday with our spouses. I had seen the original “Inside Out” when it came out, just about 9 years ago. In that Pixar animated film, a 9-year-old girl named Riley moves with her parents from Minnesota to San Francisco. Her core emotions become characters inside her animated head in the movie, a place called Headquarters: Joy, Sadness, Anger, Fear, and Disgust. It was a creative, insightful, empathic, and compassionate portrayal of how our emotions influence our relationships. The title had also been intriguing to me because some years before that I had written a rare poem about being inside and outside our mind, a haiku. I think it was published in the Houston Psychiatric Society newsletter. I did clearly recall the lines: A psychiatrist Tries to transform the inside Outside of our selves The sequel, which also depicts changes in neurons and memories by rising lines and marbles (maybe as in “losing our marbles” mentally), has been an attendance bonanza. I would say that it is also a psychiatric success. Now Riley is 13, an age typically of increasing unhappiness as puberty roars in, but worsened in her case by having to start in a new high school separated from her 2 close friends. Keeping up with the times, these friends are of different cultures and the girls play a rough game of hockey. New emotional core characters are added as the old emotions are temporally put in mental storage. They are Anxiety, Ennui, Envy, Nostalgia, and Embarrassment. As she tries to impress the older students, Anxiety takes over from Joy and she becomes more selfish and not such a good person. She has to grieve the past losses to eventually move on. However, what I told my friend afterword, the emotion that seemed missing to me was Guilt. There is a dark place in her mind that seems to have some recollection of a bit of the trauma in her past, but it is a minor character. There is little explanation of how and why she took the turn to become a good person once again. There is no therapist handy. I am left wondering where the guilt is—or was—in our presidential debate and in many of our politicians. Perhaps in our society more broadly, guilt has been disappearing. We know that it is missing in sociopathy and undue narcissism. There are more parallels to real life. There is conflict that is worsening, not being resolved. Mental disorders are particularly escalating in teenagers, especially Black females. We are just starting to try to control cell phone overuse. Sometimes in the movie, like in life, things go by so fast that you feel you cannot put it together. That left me wanting to see it again and perhaps again. In that regard, it may also benefit from group discussion afterwards, like our 2 couples did during a meal. Although the target audience seems to be teenagers, their teachers, and their parents, it felt therapeutic to me. In that regard, it may be useful for patients, and perhaps they will want to discuss the movie with their therapist. Understanding our emotions and how much cognitive control we have over them is difficult. We elders may also get benefits from watching the movie. We, too, are helped by grieving what we have lost and are losing, including people and our usual climate. We particularly remember emotionally strong memories, good and bad, as we put our lives together. But memories for some are lost in dementias. Perhaps eventually, sequels will get to our age when we are losing neurons, but hopefully getting new connections of wisdom. Note: This article originally appeared on Psychiatric Times .

CLINICAL REFLECTIONS I began my career when the major treatments for schizophrenia were haloperidol and chlorpromazine. Since then, treatments for schizophrenia have improved slowly and incrementally, especially when looking back in the rearview mirror of what treatment used to be like. Although these improvements are appreciated by senior clinicians who have been around long enough to see these changes, most patients do not know (or care) about what happened way back when and are more concerned with limitations of currently available treatments. However, the slow pace of improvement may soon change. At the time of this writing, the US Food and Drug Administration (FDA) is reviewing a new treatment approach of a nondopaminergic muscarinic agonist that, if approved as soon as late 2024, could be the beginning of a period of disruptive changes in how schizophrenia is treated.1 However, the history of new treatments coming to schizophrenia should also serve as a warning. The underuse of clozapine followed by the underuse of newer long-acting injectables (LAIs) is a reminder that treatment advances can be undone by indifference, inadequate training and leadership, and lack of accountability that have plagued the treatment of individuals with serious mental illness. These kinds of service delivery problems make it much harder to unlock the potential benefits of better treatments. Therefore, this article will take a closer look at basic aspects of current treatment and make suggestions to get more out of our current and future medication options. It is common knowledge that high-quality treatment and availability of full range of services have remained out of reach for many patients with schizophrenia. Therefore, advances in drug development face headwinds when they become available into a treatment system that lacks the institutional infrastructure to adapt new treatments. Lack of training in currently available state-of-the-art pharmacologic and psychosocial treatments, lack of training in how to engage patients with severe mental illness, and gaps in continuity of care are leading examples of factors that derail the ability to execute a personalized treatment plan. To get the most from any treatment—let alone new ones—it will require not only prior approval of a new medication but also the ability to provide the treatment infrastructure to support these treatments. Here, we review 3 examples where additional focus or training is needed to get the most out of current and future pharmacologic treatments. Hierarchical treatment planning should be considered the default approach to long-term treatment planning for individuals with schizophrenia. As shown in the Figure,3 the basic idea of hierarchical treatment planning is to address problems in sequential order rather than trying to do everything at once or becoming overwhelmed with the sheer number of problems, which could lead to decision paralysis or seat-of-the-pants treatment decisions. A hierarchical approach makes sense for a complex illness like schizophrenia. Thinking 1 or 2 steps ahead of the current situation can be helpful when thinking about the treatment approach for patients experiencing acute symptoms. The base of the pyramid in the Figure visually depicts those patients who present to your service for the first time acutely ill or unstable. One of the advantages of making a hierarchical approach an automatic routine is that it requires thinking about what to do beyond the resolution of the acute episode. These postacute considerations also better lend themselves to patient-centered approaches than what is happening in the here and now of acute treatment. The middle rung of the Figure shows the transition after the patient is stabilized, and planning can begin ahead of time. If there is a transition of care, it often helps to involve the patient, family, or other clinicians in choosing the next set of priorities aimed at reducing the burden of illness or its treatment. Once stabilized, choose 1 target at a time. The specific target goal chosen will depend on priorities established by the patient and clinician and might include tackling a persistent symptom, eliminating a problematic adverse effect (AE), or improving physical health such as smoking cessation A.s before, the choice of intervention will consider the likelihood of success, the risk of any change, and the ordering of the burden of specific AEs that are most problematic. The basic idea is to categorize the problems and then review them individually while considering priorities. What is most important to the patient? The family? The treatment team? Next, consider the likelihood of success by looking at these goals from a perspective of likelihood of meaningful response to the considered treatment intervention with leaning toward goals where the intervention is more likely to succeed. Finally, consider the risks of the potential intervention(s)—not only the absolute medical risk but also the risk tolerance of the patient and other stakeholders. Another reason to use hierarchical treatment planning is to formalize the idea of sequential learning. It is likely that some interventions will succeed and others will fail. Focusing on 1 goal at a time makes it easier to use this knowledge to improve the likelihood of success later on. Here, patience is usually a virtue. Most interventions take time to evaluate before success or failure is known. Therefore, it is important to finish a sequential intervention because prematurely stopping before knowing the outcome will invalidate any useful information that might have been gained. It is hard to appreciate the value of information when things are not going well, so coaching the value of perseverance can be helpful. Why use a name like hierarchical treatment planning? The current American Psychiatric Association (APA) guideline is comprehensive but does not emphasize sequencing. Conveying a plan that includes working on patient-centered goals later shows a level of commitment, even if these goals cannot be part of the immediate plan. It can also help with continuity of treatment planning across different services or when there is a change in staffing within the same service. Focusing on one priority at a time can be useful in training and can empower the treatment team to look beyond the immediate challenges and work on future steps that align with available treatments and the patient’s priorities. In that way, hierarchical treatment planning fits well with another high priority: establishing and nurturing positive therapeutic relationships. 2. Making the Therapeutic Relationship Your Top Priority The default approach to treatment of schizophrenia is psychopharmacology. As discussed later, being skilled in psychopharmacology is essential, but the unintended consequence of emphasizing psychopharmacology has been a deprioritization of basic skills in how to communicate and collaborate with individuals who have psychotic symptoms. In clinical conferences, presentations emphasize pharmacologic treatments without having sessions on the advances in language and communication that are quite relevant to the relationship. There are many challenges working with schizophrenia that make the connection harder to achieve, including the lack of emotional connectedness that are part of negative symptoms, the off-putting nature of someone with a perseverative delusion, or deescalating a patient whose agitation is worsened by overstimulation in an emergency department (ED). The deemphasis on learning and practicing basic skills in therapeutic relationships is shortsighted. In fact, exclusively focusing on psychopharmacology while ignoring these skills will defeat the goal of psychopharmacology, assuming that goal is better outcomes. Studies show that patient engagement is one of the biggest predictors of outcome, including outcomes in medication studies (Table 16-10). However, it seems that the emphasis on how to make such an alliance or keep it going over time is something of a lost art. But this skill should not be optional; it should be embedded in the professional identity of those treating schizophrenia. Table 16-10 covers 10 aspects of interviewing, such as techniques and alliance building that help form or maintain an alliance with the patient. Although this list is not definitive, it is a start. Focusing your efforts on the therapeutic relationship will help you remain on task. These efforts are often rewarded with better quality information coming from a less-defensive patient. 3. Embracing Expertise in Pharmacologic Management The previous section discussed the problems of single-minded pursuit of psychopharmacology at the expense of other skills crucial to the therapeutic relationship, but there is another side to this problem: how often there are suboptimal outcomes to pharmacologic therapies. Despite significant advances in our understanding of the neuropharmacology of antipsychotics in the treatment of schizophrenia over the past 30 years, a large gap exists between what we now know and actual clinical practices. Table 2 provides 10 management issues that deviate from important evidence-based information that is the standard of care today.11-18 The list is categorized by issues that are remnants from the past use of neuroleptics (first-generation antipsychotics), the present lack of awareness and/or implementation of the current evidence-based standards, and it looks to the future. Unfortunately, there has been a tendency to underuse the few therapeutic modalities that are known to make a difference, namely LAI antipsychotics and clozapine. These interventions do require training and take time to implement. The point here is that we have good evidence that clinicians have been slow to adapt to more effective treatments, and this is likely the tip of the iceberg. The acceptability to many clinicians of certain AEs is an example of complacency and continued status quo mentality. A more serious example of ignoring changes in treatments is the continued widespread use of short-acting intramuscular (IM) haloperidol in EDs without knowing the patient’s history. Thirty years ago, the risks of IM haloperidol may have been acceptable because alternatives were not available. With today’s antipsychotic armamentarium, the risk is now much greater because other formulations do not have the same life-threatening risks of neuroleptic malignant syndrome, malignant hyperthermia, or laryngeal dystonia. The routine use of IM haloperidol for all patients with acute psychosis reflects a lost opportunity for better patient-centered outcomes. Another example is the complacency in treating tardive dyskinesia (TD), passively accepting the status quo of underuse of clozapine or LAIs because of the extra time and effort needed to learn and implement these treatment options. Although this is a topic in its own right, that is not the main point here. The main point is asking questions like: “Why is our profession so accepting of clinicians who do not learn or adapt to better treatments?” The aim of this section is to suggest that the sum is greater than the individual problems. There are too many lost opportunities in offering best practices to think of them as one-off problems. In my opinion, a better explanation is that the passivity and acceptance of outdated pharmacologic principles reflects problems in training, along with complacency and reluctance to try for better outcomes. To me, this goes beyond the individual clinician and can be traced to social factors such as relative neglect of the needs of schizophrenia and related disorders, and inadequate funding across the board for quality care, training, and reimbursement. Continuing this status quo of psychopharmacology that is “good enough to get by” will threaten the new opportunities for better outcomes as other treatments become available. Concluding Thoughts The past 70 years have focused on dopamine D2 receptor blockade as the center of pharmacologic treatments. Although useful, it has had the unintended effect of holding back progress for other treatment approaches. The dopamine monopoly has made it more difficult for the field to truly let go of believing that dopamine has just about everything and anything having to do with schizophrenia. The medication pipeline for the treatment of schizophrenia has more promise now than ever. At the time of this article, it seems that we are likely to have the first true nondopaminergic antipsychotic with the upcoming FDA review of the M1/M4 muscarinic agonist, xanomeline-trospium (KarXT). This muscarinic agonist will likely be the first of a series of medications and open a new era of treatments for schizophrenia. As new options become available, there will be a collective understanding of the role of new class(es) of medications and whether they will replace current medications as first-line treatments for schizophrenia. However, if the current status quo of complacency and low expectations stays unchanged, these advances may share the fate of clozapine and LAIs as representing important and life-changing medications that have remained underused and lost opportunities for better outcomes. Note: This article originally appeared on Psychiatric Times .

Eight commonly used antidepressants have been ranked by their weight gain potential. Results of a large observational study showed small differences in short- and long-term weight change in patients prescribed one of eight antidepressants, with bupropion associated with the lowest weight gain and escitalopram, paroxetine, and duloxetine associated with the greatest. Escitalopram, paroxetine, and duloxetine users were 10%-15% more likely to gain at least 5% of their baseline weight compared with those taking sertraline, which was used as a comparator. Investigators noted that the more clinicians and patients know about how a particular antidepressant may affect patients' weight, the better informed they can be about which antidepressants to prescribe. "Patients and their clinicians often have several options when starting an antidepressant for the first time. This study provides important real-world evidence regarding the amount of weight gain that should be expected after starting some of the most common antidepressants," lead author Joshua Petimar, ScD, assistant professor of population medicine in the Harvard Pilgrim Health Care Institute at Harvard Medical School, Boston, said in a press release. The findings were published online on July 1 in the Annals of Internal Medicine . Real-World Data Though weight gain is a commonly reported side effect of antidepressant use and may lead to medication nonadherence and worse outcomes, there is a lack of real-world data about weight change across specific medications. Investigators used electronic health records from eight healthcare systems across the United States spanning from 2010 to 2019. The analysis included information on 183,118 adults aged 20-80 years who were new users of one of eight common first-line antidepressants. Investigators measured their weight at baseline and at 6, 12, and 24 months after initiation to estimate intention-to-treat (ITT) effects of weight change. At baseline, participants were randomly assigned to begin sertraline, citalopram, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, or venlafaxine. The most common antidepressants prescribed were sertraline, citalopram, and bupropion. Approximately 36% of participants had a diagnosis of depression, and 39% were diagnosed with anxiety. Among selective serotonin reuptake inhibitors (SSRIs), escitalopram and paroxetine were associated with the greatest 6-month weight gain, whereas bupropion was associated with the least weight gain across all analyses. Using sertraline as a comparator, 6-month weight change was lower for bupropion (difference, 0.22 kg) and higher for escitalopram (difference, 0.41 kg), duloxetine (difference, 0.34 kg), paroxetine (difference, 0.37 kg), and venlafaxine (difference, 0.17 kg). Escitalopram, paroxetine, and duloxetine users were 10%-15% more likely to gain at least 5% of their baseline weight compared with sertraline users. Investigators noted little difference in adherence levels between medications during the study except at 6 months, when it was higher for those who took bupropion (41%) than for those taking other antidepressants (28%-36%). The study included data only on prescriptions and investigators could not verify whether the medications were dispensed or taken as prescribed. Other limitations included missing weight information because most patients did not encounter the health system at exactly 6, 12, and 24 months, only 15%-30% had weight measurements in those months. Finally, the low adherence rates made it difficult to attribute relative weight change at the 12- and 24-month time points to the specific medications of interest. "Clinicians and patients could consider these differences when making decisions about specific antidepressants, especially given the complex relationships of obesity and depression with health, quality of life, and stigma," the authors wrote. Note: This article originally appeared on Medscape .

The US Food and Drug Administration (FDA) has approved Eli Lilly's anti-amyloid donanemab (Kisunla) 350 mg/20 mL once-monthly injection for intravenous infusion for adults with early symptomatic Alzheimer's disease (AD), which includes mild cognitive impairment (MCI) or mild dementia stage of disease with confirmed amyloid pathology. Once-monthly donanemab is "the first and only amyloid plaque-targeting therapy with evidence to support stopping therapy when amyloid plaques are removed, which can result in lower treatment costs and fewer infusions," Eli Lilly said in a statement announcing approval. "This is real progress. Today's approval allows people more options and greater opportunity to have more time," said Joanne Pike, DrPH, Alzheimer's Association president and CEO. "Having multiple treatment options is the kind of advancement we've all been waiting for — all of us who have been touched, even blindsided, by this difficult and devastating disease," Pike said. As previously reported by Medscape Medical News , the FDA approval follows last month's unanimous thumbs up by an 11-member FDA advisory panel, which concluded that the anti-amyloid agent is effective for the treatment of patients with MCI or mild dementia and that the potential benefits outweigh the risks in this patient population. Approval was based on positive data from the phase 3 TRAILBLAZER-ALZ 2 trial, which showed that donanemab significantly reduced brain amyloid plaque burden and significantly slowed cognitive and functional decline compared with placebo in early symptomatic AD. "This approval marks another step forward in evolving the standard of care for people living with Alzheimer's disease that will ultimately include an arsenal of novel treatments, providing much needed hope to the Alzheimer's community," Howard Fillit, MD, co-founder and chief science officer at the Alzheimer's Drug Discovery Foundation (ADDF), said in the Eli Lilly statement. "As a physician, I am encouraged by the potential to stop treatment, which could reduce out-of-pocket costs and infusion burden for eligible patients," Fillit commented. Participants in the TRAILBLAZER-ALZ 2 study were able to complete treatment and switch to placebo at 6, 12, or 18 months after they achieved minimal levels of amyloid plaque consistent with a visually negative amyloid PET. In the overall population of patients receiving donanemab, 17% completed treatment at 6 months, 47% at 12 months, and 69% at 18 months on the basis of an assessment of amyloid levels via an amyloid PET. The FDA's dosing instructions state that prescribers can consider stopping the drug based on removal of amyloid plaques to minimal levels as observed on amyloid PET imaging. According to Eli Lilly, the price of each vial of donanemab is $695 before insurance. A 6-month course of treatment would cost $12,522; a 12-month course, $32,000; and an 18-month course, $48,696. Patients' out-of-pocket cost for donanemab will depend on their length of treatment and their insurance. Like other anti-amyloid agents, donanemab carries the risk for amyloid-related imaging abnormalities (ARIAs). The general consensus from the FDA advisory panel was that donanemab showed "convincing" efficacy with "acceptable and manageable" risks, including the risk for ARIAs, said Committee Chairperson Thomas Montine, MD, PhD, with Stanford University in California. Note: This article originally appeared on Medscape .

Mental health care after trauma is critical, especially for people in racial and ethnic minority groups who are at higher risk for developing post-traumatic stress disorder (PTSD). PTSD can be impairing, leading to stress or fear in everyday situations that harms a person’s health and well-being. Finding effective PTSD care is challenging in general, but systemic disparities and limited access make it even harder for people from racial and ethnic minority groups. A new study funded by the National Institute of Mental Health marks a step toward reducing disparities in mental health care. It found that a collaborative care intervention delivered in real-world settings significantly reduced PTSD symptoms among patients from racial and ethnic minority backgrounds. How did the researchers treat PTSD symptoms? Collaborative care is a team-based, patient-centered approach to treating mental disorders in acute and primary care settings. Health care providers work as a team and with the patient to provide comprehensive care tailored to the patient’s needs and preferences. In a “stepped” method, providers systematically and flexibly adjust the level of care based on the patient's condition and response to treatment. While previous studies have shown that collaborative care can reduce PTSD symptoms, few studies have examined its ability to address the unique mental health needs and disparities experienced by racial and ethnic minority groups. This study, which had support from the NIH Common Fund’s Health Care Systems Research Collaboratory , is one of the first multisite studies to compare collaborative care among White and non-White trauma patients. What did the researchers do in this study? Douglas Zatzick, M.D. , senior investigator on the project, and Khadija Abu, B.A., lead author on the paper, collaborated with colleagues at the University of Washington School of Medicine’s Harborview Trauma Center. They analyzed data from a large clinical trial of stepped collaborative care conducted at 25 trauma centers across the United States. People who were 18 years and older, seeking care for an injury, and experiencing a high level of distress based on a validated PTSD measure were eligible to participate. All participants self-reported their race and ethnicity. More than half (350 patients) identified as Hispanic or non-White (Asian, American Indian, Black, Native Hawaiian or Alaskan, Pacific Islander, or another race), including those endorsing more than one race. The other 285 patients identified as non-Hispanic White. Patients were randomized to receive either enhanced usual care or stepped collaborative care. Enhanced usual care: Patients received care as usual at the trauma center, which included PTSD screenings, a baseline evaluation, and follow-up interviews. The enhanced aspect was that nurses were notified if a patient's PTSD score was above a specified threshold. Stepped collaborative care: The intervention consisted of enhanced usual care plus additional follow-up, including proactive care management, cognitive behavioral therapy, and medication. Care was tailored to each patient’s specific postinjury needs and treatment preferences. Patients who showed ongoing PTSD symptoms received stepped-up care in the form of medication adjustments, additional therapy, or both. Patients rated their PTSD symptoms at intake and 3, 6, and 12 months after their injury. They also completed measures of depression symptoms, alcohol use problems, and physical function at intake and at the three post-injury time points. For each racial and ethnic group, analyses compared scores between patients who received enhanced usual care versus the stepped collaborative care intervention. What did the researchers find in the study? Six months after their injury, Hispanic or non-White patients who received collaborative care reported significantly lower PTSD symptoms compared to those who received usual care (with no difference at 3- or 12-months post-injury). The researchers note that most post-injury care occurred within the first 6 months, possibly contributing to a lack of significant effects at 3 months and a drop off of effects at 12 months. In contrast, no significant group difference was found for non-Hispanic White patients. Those who received usual care or collaborative care showed a similar change in PTSD symptoms at all time points, indicating that the intervention was no more effective than usual care for White patents in this study. There was no change in self-reported depression symptoms , alcohol use problems, or physical function for either group, regardless of whether they received usual care or collaborative care. This suggests that the intervention specifically helps with PTSD but not with other common trauma-related symptoms. What do the findings mean? Findings from this large, randomized clinical trial support comprehensive care delivered by clinicians as effective for treating mental disorders, including PTSD. The study also suggests that this comprehensive form of care is beneficial for people from racial and ethnic minority backgrounds, who often face disparities in medical settings. Among the factors the researchers attribute to the intervention’s success for a diverse group of trauma survivors are its patient-centered focus, flexible nature tailored to individual needs, and emphasis on shared decision-making. This study is already having a real-world impact by informing trauma care guidelines in the United States. The researchers' longstanding work with this population has helped establish best practices for screening and treating mental health and substance use disorders among trauma survivors. Based on the results of this study, trauma centers are now implementing a screening and referral process for patients at high risk for mental disorders after injury as part of a new standard of care. The next step for the researchers is to test this new standard of care against the collaborative care intervention . This study was limited by collapsing racial and ethnic groups into two categories, possibly masking differences in treatment responses. Replicating the study with larger samples would allow for more nuanced comparisons to see for which groups the intervention works best. Additionally, many patients in the study had experienced prior traumatic events and been hospitalized for PTSD, which may have led to different results compared to other collaborative care studies. Researchers should continue to explore collaborative care with diverse patient groups across different health care settings and with other mental disorders to refine the intervention and help make mental health care more equitable and effective. Note: This article originally appeared on NIMH .

Individuals with anxiety have at least a twofold higher risk of developing Parkinson's disease (PD) than those without anxiety, new research suggested. Investigators drew on 10-year data from primary care registry to compare almost 110,000 patients who developed anxiety after the age of 50 years to close to 900,000 matched controls without anxiety. After adjusting for a variety of sociodemographic, lifestyle, psychiatric, and neurological factors, they found that the risk of developing PD was double in those with anxiety compared with controls. "Anxiety is known to be a feature of the early stages of Parkinson's disease, but prior to our study, the prospective risk of Parkinson's in those over the age of 50 with new-onset anxiety was unknown," colead author Juan Bazo Alvarez, a senior research fellow in the Division of Epidemiology and Health at University College London, London, England, said in a news release. The study was published published online on June 24, 2024, in the British Journal of General Practice . The presence of anxiety is increased in prodromal PD, but the prospective risk for PD in those aged ≥ 50 years with new-onset anxiety was largely unknown. Investigators analyzed data from a large UK primary care dataset that includes all people aged between 50 and 99 years who were registered with a participating practice from January 1, 2008, to December 31, 2018. They identified 109,435 people (35% men) with more than one anxiety record in the database but no previous record of anxiety for ≥ 1 year and 878,256 people (37% men) with no history of anxiety (control group). Features of PD such as sleep problems, depression, tremor, and impaired balance were then tracked from the point of the anxiety diagnosis until 1 year before the PD diagnosis. Among those with anxiety, 331 developed PD during the follow-up period, with a median time to diagnosis of 4.9 years after the first recorded episode of anxiety. The incidence of PD was 1.2 per 1000 person-years (95% CI, 0.92-1.13) in those with anxiety vs 0.49 (95% CI, 0.47-0.52) in those without anxiety. After adjustment for age, sex, social deprivation, lifestyle factors, severe mental illness, head trauma, and dementia, the risk for PD was double in those with anxiety compared with the non-anxiety group (hazard ratio, 2.1; 95% CI, 1.9-2.4). Individuals without anxiety also developed PD later than those with anxiety. The researchers identified specific symptoms that were associated with later development of PD in those with anxiety, including depression, sleep disturbance, fatigue, and cognitive impairment, among other symptoms. "The results suggest that there is a strong association between anxiety and diagnosis of PD in patients aged > 50 years who present with a new diagnosis of anxiety," the authors wrote. "This provides evidence for anxiety as a prodromal presentation of PD." Future research "should explore anxiety in relation to other prodromal symptoms and how this symptom complex is associated with the incidence of PD," researchers wrote. Doing so "may lead to earlier diagnosis and better management of PD," they added. This study was funded by the European Union. Specific authors received funding from the National Institute for Health and Care Research and the Alzheimer's Society Clinical Training Fellowship program. The authors declared no relevant financial relationships. Note: This article originally appeared on Medscape .

TOPLINE: Just one third of outpatient community mental health treatment facilities (MHTFs) in 20 states with the highest rates of opioid overdose report they offer medication for opioid use disorder (MOUD), new research showed. METHODOLOGY: Researchers surveyed administrators of 450 MHTFs in 20 states identified by high opioid overdose rates using a standardized 10-item survey. States included Arizona, California, Connecticut, and 17 others, focusing on publicly funded facilities. Researchers obtained data from the RAND Mental Health and Addiction Treatment Tracking Repository, which includes information about each MHTF. TAKEAWAY: About one third of facilities (34%) offered MOUD. Buprenorphine (84%) and naltrexone (70%) are the most frequently offered medications, while methadone (14%) is less commonly offered. Facilities with integrated treatment services are more likely to offer MOUD. A total of 70% of participants paid for MOUD with private insurance, 84% with Medicaid, 67% with Medicare, and 75% paid out of pocket. IN PRACTICE: "Outpatient community mental health treatment facilities can be an important part of the treatment ecosystem for individuals with opioid use disorders," lead author Jonathan Cantor, PhD, said in a press release. "Our findings suggest that offering integrated substance use disorder services for people with co-occurring mental illnesses is a potential avenue toward improving uptake of medication-assisted treatment among those with opioid use disorder." SOURCE: The study was led by Jonathan Cantor, PhD, of RAND in Santa Monica, California. It was published online on June 18 in JAMA Network Open . LIMITATIONS: The study's focus on states with high opioid overdose rates may limit generalizability. The extent to which facilities deliver MOUD and the number of patients receiving it remain unknown. DISCLOSURES: The study was supported by the Foundation for Opioid Response Efforts. Jonathan Cantor reported grants from the National Institute of Mental Health and the National Institute on Aging outside the submitted work. Additional disclosures are noted in the original article. Note: This article originally appeared on Medscape .

PSYCHIATRIC VIEWS ON THE DAILY NEWS Tonight is the first presidential debate for our upcoming elections. Usually, mental health gets short shrift in these debates, so here are some last-minute questions that I hope are asked. In contrast to the Goldwater Rule against any personal psychiatric analysis of public figures, asking about policies is fine. Given the worrisome rise of mental disturbances over at least the last decade, spanning both of your administrations, what would you now do to improve the mental health of our citizens? Do you think that climate instability is worsening our collective mental stability and, if so, in what ways? Has legalizing marijuana in some states been a benefit or mistake? Why or why not? Should psychedelics be legalized? Why or why not? How would you reduce the divisiveness between Democrats and Republicans? Since you both were President during the COVID-19 pandemic and now, although less severe, cases are rising again, what would you do differently if you were faced with a similar pandemic challenge once more? What do you think about physician-assisted suicide? How do you like our Surgeon General publicly coming out about our loneliness, social media harm, and gun control problems, and what would you do to address those problems? Do you think that your administration would be helped by having a psychiatrist consultant at a high level in your government? How would you assess your own mental health in your readiness for the stress and challenges of being President at your advanced ages, and would you agree to have an expert and objective mental health exam before the election? Perhaps we can use any attention—or none—in this debate about mental health to make recommendations for the next time around. What would you like to ask? Note: This article originally appeared on Psychiatric Times .

I read this quote every morning and it helps me feel process life and it's moments of vulnerability. Live the Life you've always dreamed of. Be FEARLESS in the face of adversity. Never stop learning. Use your imagination whenever possible. Recognize the BEauty that surrounds YOU. Remember where you came from, but don't lose sight of where you are going. BE THE ARCHITECT of your destiny. This life is YOURS TO CREATE!

Loss is unavoidable on the human journey. Where there is loss, grief follows. Grief can be overwhelming due to the intensity of emotions involved. In the aftermath of a major loss, people often struggle to return to their routines in a way that honors and makes space for their bereavement. Grief rituals offer a powerful means of working with and healing from loss that can be incorporated into daily life. Personalized grief rituals allow for greater flexibility, customization, and repetition. This article presents an easy-to-follow template for designing a grief ritual tailored to your particular loss. Carrying out such a ritual is an empowering and hands-on way of working with your grief. A grief ritual may not be appropriate in some cases. Consult with a professional before conducting a grief ritual if you struggle with depression, suicidality, or other mental health issues, or if you feel ill-equipped to handle the intense emotions that may arise. What is a Ritual? Any event or activity with structure, intention, and an element of the sacred can be a ritual. Some examples include meditating each morning, singing “happy birthday” at a celebration, or planting and tending a memorial garden. Regardless of the content, rituals create a space to honor what matters most and to welcome insight, growth, and healing. How Rituals Help with Grief The English word “grief” derives from a Latin word that means “heavy,” “weighty,” and “burdensome.” Rituals help alleviate the burden of grief after a major loss. They do this by promoting acceptance of the loss, emotional expression, and a feeling of control. Rituals also help maintain a bond with what has been lost and provide an opportunity for reflecting on how to go forward. Carrying out a ritual connects a person to whatever they consider sacred, be it a higher power, a state of consciousness, or their most cherished values. GRIEF RITUALS ​ ​ ✔ Acceptance of loss ​✔ Sense of control ​✔ Processing of emotions ✔ Creation of meaning ✔ Maintenance of bond with deceased ✔ Comforting routine ✔ Expression of beliefs & values ✔ Healing, growth, & insight Adopting a Personal Grief Ritualfgxhdfgjugf To be effective, a grief ritual should be tailored to your particular loss, belief system, and immediate environment. Below are steps you can follow to design a grief ritual that is right for your situation. Feel free to make adjustments based on your culture, setting, and religious or spiritual beliefs. ​Grief Ritual Steps ​1. Choose a meaningful object 2. Make it sacred ​3. Incorporate movement ​4. Interact with chosen object ​5. Create closure and repeat Choose a Meaningful Object Grief rituals benefit from incorporating a meaningful physical object. If possible, select an object with a connection to your loss. If you are grieving the loss of a loved one or relationship, this might be a cherished piece of jewelry, an article of clothing they wore, a gift they gave you, a letter they wrote, or a photograph. If your loss does not involve a person, you may still be able to find an object related to the loss. For example, if you are grieving the end of a job, you could choose an object from that role—a pen, ID card, uniform, or business card. If you are unable to think of an object, select something with symbolic value from the natural environment—a rock, flower, seashell, or feather. Make it Sacred Rituals should have an element of sacredness to distinguish them from mundane activities, such as getting dressed, cleaning, or driving to work. Lighting a candle, visiting a special place, or reciting a prayer, mantra, or intention are all good options for marking the start and conclusion of your ritual and emphasizing its sacredness. Rituals should also include steps performed in a certain order. This provides a structure that guides you through the ritual, which can be helpful if you are overwhelmed with emotion. Incorporate Movement Research suggests that connecting with your body can help with expressing and processing difficult emotions, which is one of the most important benefits of a grief ritual. Incorporating movement into your grief ritual can be an effective way to do this. A walk in nature—even if just around the block or in a park—can serve this function. If you are mourning the loss of a person, you might walk in a place that reminds you of them. Some find it meaningful to visit the site where their loved one died or where their remains are located. If it is not possible to go for a walk, consider whether there are other ways to use movement in your ritual. For example, you could dance to a song that speaks to your loss. If you live near water where it is safe to swim, you could immerse yourself or tread water as part of your ritual. Interact with Chosen Object Rather than just having an object present, grief experts recommend using the object in some way. This symbolizes moving the pain of grief to a place where it can be worked with and transformed. For example, if you wrote a letter expressing your feelings about a relationship that ended, you could shred and bury it as a way of releasing your emotions. If you chose a rock as your object, imagine your anger or guilt being absorbed into it, and then drop the rock into deep water as a way of letting go of what burdens you. If your object is a feather, place it in a stream, and watch as it slowly fades from view. Take adequate time to feel and express any emotions that come up in your grief ritual. Another option is to create a small altar somewhere in your home. Place your chosen object on the altar and treat it as a sacred space where you can regularly meditate, pray, or sit in quiet contemplation. Create Closure & Repeat After performing your ritual, create a sense of closure before returning to your day. Some good options are reciting a mantra, expressing an intention, praying, meditating, or extinguishing a candle you lit to begin the ritual. This helps mark the end of your ritual and the return to your normal activities. Rituals often increase in power and significance when repeated. If your ritual is elaborate or time-consuming, it may make sense to repeat it on an occasional basis, such as on the anniversary of the loss. But simpler rituals can often be integrated into your daily life. For example, you could light a candle and meditate or pray each morning to start your day. Or you could go on a short walk in the evenings as a way of reflecting on your loss. Experiment with what works best for you. Grief Rituals in Action Below are examples of how two people designed effective grief rituals using the previously outlined steps: End of a Relationship Daniel is struggling in the months following his divorce. He is devastated by the end of his marriage, but also angry and hurt, especially about his ex-wife's affair. Here’s how Daniel created a ritual to work with his grief: ​Ritual Step ​Action ​Choose a meaningful object ​Daniel decides to write a letter to his ex-wife expressing his anger and other emotions. Make it sacred Daniel finds a quiet place to write the letter and lights a candle to mark the start of his ritual. Incorporate movement Daniel walks to an empty field near his house. He then digs a hole in the ground. Interact with chosen object Daniel reads the letter aloud, expresses his emotions, shreds the letter, and places the many pieces into the hole. Create closure & repeat Daniel plants a sapling in the hole with the shredded letter, returns home, and decides to revisit the site in a month. Death of a Loved One Marisa is heartbroken after losing her older sister, Gabriela. In addition to mourning her sister’s passing, Marisa is sad that she did not get a chance to say goodbye. This is how Marisa designed and carried out a ritual to aid her grief process: ​Ritual Step Action Choose a meaningful object On one of her walks, Marisa finds a colorful feather, which reminds her of her sister’s love of birds. Make it sacred Marisa decides to carry out her ritual at a nearby stream in a beautiful setting that feels special to her. Incorporate movement ​Marisa walks through the woods to the stream and finds a quiet spot on its banks. Interact with chosen object Marisa says goodbye to her sister and wishes her spirit well. She then gently releases the feather into the stream. Create closure & repeat After the feather disappears into the distance, Marisa returns home, resolving to revisit the ritual site every weekend. Your grief ritual can and should look different from these examples, as it will be unique to your loss, beliefs, and preferences. Be creative as you decide how to incorporate the elements mentioned in the article. Remember to include each of the outlined steps in whatever ritual you choose: Choose a meaningful object, make it sacred, incorporate movement, interact with chosen object, and create closure and repeat. While not a cure for loss, carrying out a well-designed personal grief ritual has many potential benefits, such as helping you accept the loss, process your emotions, have a sense of control, and maintain your bond with the deceased, among others. Repeating your ritual and making it part of your routine can increase these benefits and give meaning and structure to your life.

During the coronavirus pandemic, public health measures and restrictions impacted in-person health care visits, leading to a surge in telehealth services as a way of accessing assessment and treatment. Particularly in mental health care, telehealth saw a significant rise, and usage remains high even post-pandemic. However, despite the increased utilization of telehealth services, there's a limited understanding of the availability and structure of these services. What did the researchers do? In an NIMH-funded study, researchers led by Jonathan Cantor, Ph.D. , of the RAND Corporation investigated the availability of different types of telehealth services and the time it took patients to access telehealth care. Between December 2022 and March 2023, researchers contacted more than 1,900 outpatient mental health care facilities to ask about telehealth services. The underlying sample came from outpatient mental health treatment facilities, not individual practitioners. The researchers used a secret shopper approach, using a script that mirrored information a prospective patient might ask when inquiring about telehealth services. The secret shoppers asked about the availability of telehealth services for treating major depressive disorder, generalized anxiety disorder, or schizophrenia. They also asked about the specific services offered via telehealth (behavioral therapy, medication management, diagnostic services) and the number of days they would have to wait before having their first telehealth appointment. Both men and women served as secret shoppers, and the names used by the shoppers were chosen to reflect a variety of racial and ethnic backgrounds. What did the researchers find? Out of the more than 1,900 facilities contacted, the researchers received replies from 1,404. Among these, 1,221 were accepting new patients. Of those 1,221 facilities, 80% (980) offered telehealth services. Out of the 980 treatment facilities that offered telehealth services: 97% provided counseling services 77% provided medication management 96% provided diagnostic services Among the facilities that responded to the telehealth question, the researchers found: Not-for-profit and for-profit private treatment facilities were more likely to offer telehealth services than public treatment facilities. Treatment facilities in metropolitan areas were more likely than non-urban areas to offer medication management but less likely to offer diagnostic services. The average wait time for a telehealth appointment was 14 days (ranging from 4 to 75 days, depending on the facility contacted). What do the findings mean? The researchers found that some of the facilities they initially reached out to for information did not respond, suggesting that people looking for any type of mental health care may experience barriers to accessing it. Of the facilities that did respond, most were accepting new patients, and most provided telehealth services; however, the availability of those services and the type of care offered varied by location and state. This suggests there may be disparities in access to telehealth services across the United States. The researchers note that telehealth services and availability may differ at health centers not included in this study and that the availability of technology that makes telehealth possible—such as broadband services—was not examined in this analysis. Note: This article originally appeared on NIMH .

It is officially summer in the northern hemisphere, the season for summer vacation travel. My wife and I are on vacation in Manhattan. Actually, perhaps we are on an ongoing vacation of sorts since I retired from my formal psychiatric clinical and administrative work a dozen years ago. Usually, nonprofessional travel is considered as a vacation in the sense of a getaway from the routine. Perhaps it can be more than that. It can be part of psychiatry. Travel can perhaps be therapeutic. Travel can also be part of a new focus in psychiatry called lifestyle psychiatry.1 Lifestyle psychiatry is the theme of the 2025 American Psychiatric Association Annual Meeting. The Wall Street Journal  has long had a section on Lifestyle in their daily paper, and Travel is one of the subsections. Taking travel as a therapeutic lifestyle connects the 2 threads. This sort of focus has been developed over recent years by the School of Life, an organization begun in England in 2016 and now global. Its goal has been to translate mental health principles into everyday life. I think they have done that remarkably well, and in a way that is easy enough for the public to understand and appreciate, but with some sophistication. Therapeutic travel means to consciously pick a destination that is likely to inspire and enchant in a way that enhances well-being, maybe even be healing. In one of products of the School of Life, A Therapeutic Atlas , images of particular places, also accompanied by short essays, illustrate the potential places that can liberate our minds in different ways.2 This atlas can be read in conjunction with planned travel, afterwords, or I suppose, even to review past travel with a new perspective. Although most of the places in the book may seem exotic, really, the travel can also be staycations at home. In the section of the atlas on Holidays, I found the Nightclubs on pages 54-55. I was attracted to that because it is in Manhattan—where we have headed. The time in the book is 1978, with an image of the infamous Studio 54, with the statement: “It can take serious pain before we learn to dance with true silliness.” I think that I have learned over the years, or at least have been told, that I can dance pretty silly. My wife and I never went to such clubs, but instead jazz clubs which do not often include dancing. Just the music. By you can jive and bob around in your seat, and be swept away with the healing force of music in a connected and collective multicultural audience. We are planning to go to a special place and event, billed as New York’s biggest, which I likely will cover in the next column. A hint: maybe it has something to do with one of my favorite songs and pictures of Rusti and I dancing, titled “Dancing to the End of Love,” after the song of that name by Leonard Cohen. Sort of accompanying the book is a set of Travel Therapy cards, designed to “deepen and transform the experience of travel.” The first is “What is this destination trying—in its way—to teach you?” A later card is: “How could you change your life in some way because of what you have seen here?” Rusti and I may also share some of our answers. Perhaps you or your patients have had some therapeutic travel. If so, please let us know. Note: This article originally appeared on Psychiatric Times .