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The gut-brain axis is a bidirectional communication network that links the enteric and central nervous systems. According to an article published in Integrated Medicine: A Clinicians Journal, this network is not only anatomical, but it extends to include endocrine, humoral, metabolic, and immune routes of communication as well. The autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and nerves within the gastrointestinal tract, all link the gut and the brain, allowing the brain to influence intestinal activities, including activity of functional immune effector cells; and the gut to influence mood, cognition, and mental health. Gut microbiota are well known to support tight junction integrity between enterocytes . It should therefore come as no surprise that dysbiosis and associated increases in intestinal permeability are now recognized features of rheumatoid arthritis, Alzheimer’s disease, asthma, autism spectrum disorders, and other systemic conditions both inflammatory and otherwise. In recent years, there has been a tremendous amount research validating the mechanisms and role of the microbiome and probiotics in managing inflammatory conditions, particularly IBD. Depression is increasingly recognized as having an inflammatory component; indeed, anti-inflammatory drugs, such as COX-2 inhibitors, have previously demonstrated efficacy in major depression A new class of probiotics, known as psychobiotics or psychomicrobiotics , has emerged in the last decade and is being fervently embraced by many health care practitioners as a nontoxic intervention for various psychiatric conditions. Several clinical trials have now documented effects, or lack thereof, of certain probiotics for depression and anxiety. In a 2017 systematic review by Wallace and Milev of 10 clinical trials, most of the studies found positive results on measures of depressive symptoms. Because clinical trials on probiotics for depression and anxiety have been heterogeneous in terms of dosing, probiotic strain selection, and length of treatment, further randomized controlled clinical trials are warranted to validate the efficacy of this promising intervention. Studies from animal models conducted by independent research groups have corroborated findings of gut dysbiosis and its relation to monoamine disruptions seen in clinical depression, connecting gut microbiota with mood.44-48 In addition, intestinal permeability defects are thought to underlie the chronic low-grade inflammation observed in stress-related psychiatric disorders.49 Those with symptoms of depression frequently exhibit increased expression of proinflammatory cytokines, such as IL-1β, IL-6, tumor necrosis factor-α, as well as interferon gamma, and C-reactive protein.50-51 , 52 Gut microbiota influence transcription of these same cytokines, with dysbiosis triggering the so-called inflammasome pathway, whereas beneficial metabolites (SCFAs in particular) reduce production of proinflammatory cytokines, such as NF-κB.53

On July 16, 2022, the Lifeline transitioned away from the National Suicide Prevention Line reached through a 10-digit number to the three-digit 988 Lifeline. Psychiatric Times provides a year end review of their progress below: A year ago, the National Suicide Prevention Lifeline switched to its new 3-digit number, 988. Since its launch, the Lifeline has received a startling number of contacts: over 5 million, including more than 1.43 million calls, 416,000 chats, and 281,000 texts.1 But is it effective in saving lives? “The transition to the 988 Suicide & Crisis Lifeline has sparked a transformational moment in behavioral health care in this country. For the first time in my 26-year career history, every state and territory is talking about improving their behavioral health crisis systems,” said Monica Johnson, MA, director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration (SAMHSA). “While we know that there is still much work to do to achieve a robust response system for mental health and substance use crisis care across the country, we have accomplished a lot in the past year. The data show that, since the transition to 988, more people are reaching out for help, and they are getting a response much faster than ever before to get the help that they need in a time of crisis.” Figure 1. May 2023 Contacts According to SAMHSA, the Lifeline receives an average of approximately 350,000 contacts per month. During May 2023 alone, contacts increased by more than 40% in calls, chats, and texts alike compared with the previous year ( Figure 1 ).2 “We are seeing this increase in contacts, and I do not think that is a failure of the system; I think that’s showing it’s a success. Increasing numbers means that we might be catching some folks before they get to that terrible stage,” said Scott Zeller, MD, vice president of acute psychiatry at Vituity, assistant clinical professor of psychiatry at the University of California, Riverside School of Medicine, and Psychiatric Times editorial board member. “Anything we can do to reduce suicide is a win.” Let’s take a look at the Lifeline, still in its infancy, and evaluate the current benefits and potential areas for improvement. Decreased Wait Times Figure 2. Monthly Comparison of Average Answer Speeds2 National overall answer rates have increased to 91% as of December 2022, compared with 64% from December 2021, meaning—no matter the outcome—more individuals in need of help are being connected to a counselor. Additionally, individuals who contact 988 are spending much less time waiting for a counselor; the average overall wait time decreased from 2 minutes and 52 seconds to just 44 seconds.1 Monthly average wait times are even shorter in 2023 ( Figure 2 ).2 “Seconds count when somebody is in crisis. If someone finds themselves on a long hold, waiting for an answer, that could lead to frustration or hanging up the phone, and that is when bad things start to happen. The more quickly we can get them access, the better,” said Zeller. According to research, 24% of suicide survivors aged 13 to 24 years said it took them less than 5 minutes between deciding to attempt suicide and trying.3 Data from another study showed that of 82 patients referred to a psychiatry department post suicide attempt, nearly half (47.6%) reported their suicidal deliberation lasted 10 minutes or less.4 Better Text Response Prior to 988’s launch, the Lifeline could only sufficiently process 56% of the text messages and 30% of the chats received. In contrast, although text volume has now increased by over 700%,1 the text answer rate in May 2023 was an impressive 99%.2 Connecting via text may be more important to youth who contact the Lifeline. With the average teenager sending and receiving 5 times more text messages a day than a typical adult, this may be their preferred method of communication.5 “One of the biggest impacts that 988 is having, when you look at the data, is the dramatic increase of texting services,” said Margie Balfour, MD, PhD, chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. “You should be able to provide services in ways that people like to communicate, and it really shows that there was an unmet need in this area.” Target Group Specificity Figure 3. Lifeline Specialized Services The Lifeline also now offers specialized services for various populations ( Figure 3 ). Other pilot programs are expected to follow, with potential Lifeline subnetworks for individuals who are hearing impaired and for American Indian/Alaska Natives.6 Area Code Issues Ideally, 988 calls should be answered as locally as possible. A national backup crisis center handles any calls that local crisis centers cannot answer, but how exactly is an individual’s local center determined? Unlike 911, 988 does not geolocate those who contact the Lifeline. Instead, 988 uses their area code to determine the closest call center.7 Unfortunately, this means if an individual living in New York has a Texas area code, the call center will be directed to the closest center in Texas, which will not be able to deploy a mobile team to a New York location. More on 988 Inside 988 Lifeline: Conversations with a Crisis Counselor Leah Kuntz; Jennifer Lang 988: The 1-Year Anniversary Bob GebbiaTherein lies the problem. Although geolocation would help in providing localized services, some callers may not want their location to be known. “I think there is a really good argument from the advocate side, saying ‘We do not want to be tracked.’ What if I just want to call and talk to you and say that I feel hopeless? It does not mean that I want you to know where I am to send cops, which is really what this all comes down to. There is not an easy solution here. Ethically and philosophically, this is one of the most interesting components of the 988 rollout so far,” said Tony Thrasher, DO, MBA, DFAPA, medical director of crisis services at Milwaukee County Behavioral Health Division, Wisconsin. Lack of Quality Consistency Every 988 call center is unique in how it responds to crisis callers. Some states had robust crisis lines prior to 988. Arizona, for example, is being looked at as an example model, Balfour told Psychiatric Times . Built on the backbone of Medicaid rather than telecommunication fees, this preexisting system has established trust in the community over the past 2 to 3 decades. However, some call centers do not have the privilege of a preexisting system. “When you ask what happens when you call 988, in Arizona, you are going to get a crisis line that has been active for years. They have the infrastructure and resources to be able to dispatch 24/7 clinician mobile crisis teams, who can do interventions in the field and then resolve many of those crises. If needed, they can bring individuals to crisis stabilization centers, or crisis receiving centers that can then provide crisis care,” said Balfour. “ If you call 988 in a community that does not have that… What actually happens is very local resource dependent. Different communities carry much different loads and are at different stages of development.” Another example is Montgomery County, Ohio. Before the launch of 988, the county created Crisis Now, a 3-pronged approach to delivering crisis services that included a hotline and mobile response teams. In the initial 6 months of Crisis Now, 89% of calls to the hotline were resolved over the phone and 77% of the mobile crisis responses were resolved in the community. Upon 988’s launch in July, the already-in-place hotline also began taking local 988 calls, and felt better prepared to handle the switchover.8 Compare this with Hanover in York County, Pennsylvania. Prior to 988’s launch, the rural center, TrueNorth Wellness Services, reported difficulty hiring counselors and were uncertain they would be able to handle an influx of contacts.9 Uncertain Expectations When you call 911, you know exactly what you are getting: an ambulance, a firetruck, or police, or maybe a combination depending on the situation. What do callers get when they call 988? “It comes down to supply and demand,” said Thrasher. “What type of workers can each area find to respond to calls? There is a large push for less law enforcement presence and higher mental health presence. The hard part is, from a supply and demand focus, there are markedly more law enforcement workers, and they are paid significantly better than mental health workers. That is no knock on law enforcement —I think they earn what they get. But if we as a culture want to bring the mental health after-hours response 24/7, 365 days, on holidays, we need to pay them. One reason law enforcement and fire do that is because they are compensated to do so.” To build these expectations, we must know: Who is running that response team? What is their supply and demand? What is their funding? Do they have enough funds to have a 24/7 mental health work? The Need for More Funding The federal government has invested close to $1 billion into the 988 Lifeline, including a little more than $500 million in the federal spending bill.10 In May 2023, the US Department of Health and Human Services announced an additional $200 million in new funding for states, territories, and tribes to build local capacity for the 988 Suicide & Crisis Lifeline and related crisis services.11 Figure 4. States With Enacted Legislation to Sustain 98812 However, as contacts continue to pour in, some local Lifeline call centers may not be able to maintain their coverage when federal funding decreases. As of early June 2023, just 26 states had enacted legislation to maintain 988, and only 5 of those states had enacted legislation to sustainably fund 988 through telecommunications fees, as enabled by the National Suicide Hotline Designation Act of 2020 ( Figure 4 ).12 “I think we need to have parity of these 4 services: fire, EMS, law enforcement, and mental health. To do so, they should all be in the same room and should all have the same sort of requirements of staffing and quality of care. But then we also must get the same degree of funding,” said Thrasher. “Mental health is not near those other 3 in anything resembling sustainable funding. The public does not see a mental health call like a fire or a police call.” Looking Ahead Comparisons are often made between 988 and 911. Notably, 911 took 13 years to reach a modicum of stability; the first 911 call was placed in 1986, but 911 was not designated the nationwide emergency telephone number until 1999.13Furthermore, there are more than 5700 primary and secondary Public Safety Answering Points to answer 911 calls, as compared with approximately 200 988 centers.1,14 911’s success was not built in a year, and to expect otherwise for 988 is irrational. Our experts agreed: “Emergency psychiatry is all about taking care of people in their most vulnerable moments on their worst days. 988 has now led to more access to services to help them with that, including services that do not necessarily culminate in the emergency department,” Thrasher told Psychiatric Times . “It is not to the scale that I think we want to see it yet, but it is a really good start.” “It is a first step in what I think is a longer journey. It has been a catalyst for both the federal government and for communities to start to look at what we need,” said Balfour. “The promise of 988 is not there yet, but I think it is effective in getting us closer.” In a Psychiatric Times online poll, 70% of responders said they had discussed 988 with their patients.15 Have you discussed 988 with patients or their families? Source: Psychiatric Times Updated 7/13/23 to reflect new statistics. References 1. Saunders H. Taking a look at 988 suicide & crisis lifeline implementation. KFF. February 23, 2023. Accessed May 31, 2023. https://www.kff.org/other/issue-brief/taking-a-look-at-988-suicide-crisis-lifeline-implementation/ 2. 988 Lifeline performance metrics. SAMHSA. Accessed May 31, 2023. https://www.samhsa.gov/find-help/988/performance-metrics 3. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav . 2001;32(suppl 1):49-59. 4. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry . 2009;70(1):19-24. 5. Lenhart A. Part four: a comparison of cell phone attitudes & use between teens and adults. Pew Research Center. September 2, 2010. Accessed June 14, 2023. https://www.pewresearch.org/internet/2010/09/02/part-four-a-comparison-of-cell-phone-attitudes-use-between-teens-and-adults/ 6. Stracqualursi V, Howard J. Forthcoming 988 suicide prevention hotline plans pilot program specifically for LGBTQ community. CNN. July 9, 2022. Accessed June 14, 2023. https://www.cnn.com/2022/07/09/politics/988-national-suicide-prevention-lifeline-lgbtq-subnetwork-wellness/index.html 7. 988 Geolocation Report — National Suicide Hotline Designation Act of 2020. Federal Communications Commission. April 15, 2021. Accessed June 14, 2023. https://docs.fcc.gov/public/attachments/DOC-371709A1.pdf 8. Six months after launch, how is 988 doing? National Association of Counties. January 13, 2023. Accessed June 14, 2023. https://www.naco.org/articles/six-months-after-launch-how-988-doing 9. Mencia A. Pennsylvania gears up for launch of new 988 mental health hotline. Axios Philadelphia. July 13, 2022. Accessed June 14, 2023. https://www.axios.com/local/philadelphia/2022/07/13/988-mental-health-hotline-pennsylvania 10. Chatterjee R. 988 Lifeline sees boost in use and funding in first months. GBH. January 16, 2023. Accessed June 14, 2023. https://www.wgbh.org/news/national-news/2023/01/16/988-lifeline-sees-boost-in-use-and-funding-in-first-months 11. HHS announces additional $200 million in funding for 988 Suicide & Crisis Lifeline. US Department of Health and Human Services. May 17, 2023. Accessed June 14, 2023. https://www.hhs.gov/about/news/2023/05/17/hhs-announces-additional-200-million-funding-988-suicide-crisis-lifeline.html 12. State legislation to fund and implement the 988 Suicide and Crisis Lifeline. National Academy for State Health Policy. Updated June 6, 2023. Accessed June 14, 2023. https://nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/ 13. 911 and E911 Services. Federal Communications Commission. Accessed June 14, 2023. https://www.fcc.gov/general/9-1-1-and-e9-1-1-services#:~:text=The%20official%20emergency%20number%20in,States%20for%20all%20telephone%20services 14. 10 things you might not know about the United States’ 911 emergency telephone number. Walden University. Accessed June 14, 2023. https://www.waldenu.edu/online-masters-programs/ms-in-criminal-justice/resource/ten-things-you-might-not-know-about-the-united-states-911-emergency-telephone-number 15. What have you heard about 988? Psychiatric Times . May 25, 2023. https://www.psychiatrictimes.com/view/what-have-you-heard-about-988

NeuroStar Advanced Therapy has received clearance from the US Food and Drug Administration (FDA) as an adjunct in the treatment of major depressive disorder (MDD) in adolescent patients aged 15 to 21 years. This clearance marks NeuroStar as the first and only transcranial magnetic stimulation (TMS) treatment that is FDA-cleared for this age group. MDD in adolescent patients is also the fourth FDA-cleared indication for NeuroStar,1 along with treatment of MDD in adults, treatment of obsessive-compulsive disorder in adults, and anxiety symptoms in adults with MDD. “The prevalence of depression in adolescents and young adults has been accelerating since the COVID-19 pandemic,” said Kenneth Pages, MD, medical director of TMS of South Tampa, in a press release. “The current treatment options available for adolescents are extremely limited, compared to those available for adults. NeuroStar’s TMS therapy now offers a promising first-line treatment for adolescents, backed by real-world data and impressive response rates consistent with response rates for adults. This advancement has the potential to set a new treatment paradigm for how we address depression in our youth.” The FDA’s decision to grant clearance for this indication is informed by an analysis of real-world data collected through NeuroStar’s proprietary TrakStar® platform. Among the 1169 adolescents analyzed, 78% showed clinically meaningful improvement in depression severity. The FDA reviewed this data set alongside clinical literature and concluded that NeuroStar TMS, when used as an adjunct to antidepressant therapy, is substantially equivalent in terms of safety and effectiveness compared to antidepressant therapy alone in this population. The coil design versatility of NeuroStar also allows providers to address the immediate treatment needs of adolescents with MDD symptoms without requiring additional hardware upgrades or purchases. This feature gives adolescent patients and their families a new option when weighing alternative treatments for depression. Access to effective treatment for MDD is important for all patient populations, as MDD is the fourth leading cause of disease burden globally. “Receiving FDA clearance to treat the adolescent segment aged 15 and up is a treatment solution that is long overdue in the mental health industry,” said Keith J. Sullivan, president and CEO of NeuroStar developer Neuronetics Inc, in a press release. “We are excited to offer NeuroStar TMS therapy as a new option for young people and for their concerned parents who have struggled to find a treatment they can be confident in. As a company, we will be focused on driving even more awareness and education about NeuroStar given that this new clearance grows our total advdnhfjshydfdressable market in MDD by 35%.” Note: This article originally appeared on Psychiatric Times

PSYCHIATRIC VIEWS ON THE DAILY NEWS But I do see a way. There is a narrow way through.” - Paul Atreides in “Dune” “All the world is a narrow bridge, and most important is not to be overwhelmed by fear.” - Rabbi Nachman of Breslov One of the definitions of a prophet is one who foretells future events correctly. We have had a few such possibilities lately. One is the featured character Paul Atreides in the movie “Dune.” As a possible Messiah, and with the help of the psychedelic spice, he foresees various future scenarios involving planetary war. The Free Press began a weekly series on past prophets in the United States. First, on March 2, featured Marshall McLuhan of “the medium is the message” fame. Decades ago, he seemed to foresee our internet age and its profound rewiring of our society and brains. Next, on March 11, was Bayard Rustin, the civil rights advocate and ally of the Rev. Dr Martin Luther King Jr. He predicted that psychologically traumatizing White individuals to increase their guilt would be likely to backfire, as perhaps may be now happening with diversity, equity, & inclusion consultants. March 16 featured D.A. Henderson who, back in 2006, warned against a global shutdown in an epidemic because it would lead to economic and social disruption. Even though I was way off in predicting how long the COVID-19 pandemic would last, as discussed in my last column, these portraits of prophets inspired me to responsibly see how I did so far in a series of predictions starting just about a year ago. One might assume that since psychiatrists have some expertise in understanding human behavior, that our prediction ability would increase. Therefore, in ensuing columns, I will try to fairly cover my previous predictions about psychiatry and artificial intelligence, psychedelics, politics, naming, social psychopathologies, indigenous individuals, eulogies, and predictions. My prediction is that I will complete them on April 1, April Fool’s Day 2024. Wouldn’t that be fitting? Note: This article originally appeared on Psychiatry Times

A diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults was associated with a 7-year reduction in life expectancy, on average, compared to the general population, findings from a large study show. Compared with peers without ADHD, males with ADHD in the matched retrospective UK study died an estimated 7 years earlier, and females with the diagnosis died around 9 years earlier. "We believe that this is unlikely to be because of ADHD itself and likely caused by modifiable factors such as smoking, and unmet mental and physical health support and unmet treatment needs," the authors wrote, adding "The findings illustrate an important inequity that demands urgent attention." The findings were published online January 23 in The British Journal of Psychiatry . Consequences of Impaired Executive Function Previous research has shown that adults with ADHD experience more unemployment, financial problems, contacts with the criminal justice system, and homelessness than those without the condition. ADHD has also been linked to a higher risk of suicide, and an earlier meta-analysis of eight studies found that people with ADHD are twice as likely as those in the general population to die prematurely. They are also more likely to engage in risky behaviors, such as smoking, drug use, and drinking, investigators noted. To learn more about ADHD and life expectancy, investigators examined electronic medical records from 794 UK primary care practices. The analysis included data on 30,039 adults diagnosed with ADHD at any point in their lives and 300,390 matched controls. The primary outcome was all-cause death. In the UK, primary care offices are updated with patients' deaths by the National Health System Personal Demographic Service. Investigators used a Poisson model to estimate the mortality rate by single year-of-age for those with ADHD and the control group. They then used the modelled rates to estimate life expectancy at age 18 years using the period life table method as described by the Office for National Statistics. The median age at cohort entry for males was 18.95 years and 22.10 years for females. Shorter Lifespans Mortality rates were higher in the ADHD group (males, 0.83%; females, 2.22%) compared to the control group (males, 0.52%;females, 1.35%). Among those with ADHD, death was 1.89 times more likely in men (95% CI,1.62-2.19) and 2.13 times more likely in women (95% CI, 1.79-2.53) during follow up compared to controls. ADHD was associated with a reduction in total life expectancy of 6.78 years in males (95% CI, 4.50-9.11) and 8.64 years in females (95% CI, 6.55-10.91). Average age at death for the ADHD group was 73 years in men (95% CI, 71.06-75.41) and 75 years (95% CI, 72.99-77.11) in women. For the control group, average age at death was 80 years (95% CI, 79.34-80.74) for men and 84 years for women (95% CI, 83.12-84.44). The authors called the findings "extremely concerning," adding that for individuals with ADHD, there are often associated mental health challenges, including substance use, smoking, or compulsive behavior that may contribute to premature death. “Only a small percentage of adults with ADHD have been diagnosed, meaning this study covers just a segment of the entire community," lead author, Elizabeth O’Nions, PhD, epidemiologist at the Bradford Institute for Health Research, University College of London, said in a press release. “More of those who are diagnosed may have additional health problems compared to the average person with ADHD. Therefore, our research may over-estimate the life expectancy gap for people with ADHD overall, though more community-based research is needed to test whether this is the case,” she continued. Study limitations include the lack of information about cause of death and wide confidence intervals around certain point estimates, likely due to the relatively small number of participants with ADHD. In addition, the findings are probably not generalizable to other countries, settings, or time periods, the authors wrote. Experts Weigh In Several experts who were not part of the study weighed in on the findings in a statement from the UK-based nonprofit and independent Science Media Centre. Philip Asherson, PhD, professor of molecular psychiatry at King's College London, said the study illuminated the impact of an ADHD diagnosis on life expectancy. While the causes of early death are not yet confirmed, he noted, ADHD has been linked to cardiovascular disease and cancer and may be linked to autoimmune and other physical health disorders. "ADHD is increasingly recognized as a serious condition in adults associated with poor health outcomes," Asherson said. Of particular concern are limited access to diagnosis and treatment including psychosocial support, he said, adding, "until this is addressed, the shorter life expectancy demonstrated in this study is likely to continue.” Also commenting on the study was Oliver Howes, PhD, MBBS, professor of molecular psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London. “The study adds to lots of other evidence that people with other mental illnesses die sooner than people without mental illness to show this for ADHD as well," he said. The study's use of a large UK database is a strength, but a limitation was that investigators were unable to study how participants' ADHD diagnosis date was related to comorbid conditions or treatment efficacy. "More work is needed to understand what underlies the link between ADHD and premature death,” he said. Note: This article originally appeared on Medscape .

TOPLINE: Common childhood stressful life events like starting a new school, moving homes, or having a new sibling are associated with an increased risk for atopic dermatitis (AD) activity and severity in children, a study suggests. METHODOLOGY: Researchers conducted a longitudinal cohort study of 13,972 children aged 1-8.5 years from the Avon Longitudinal Study of Parents and Children in the United Kingdom; 4454 had AD. Primary caregivers completed standardized questionnaires on about 15-17 age-appropriate stressful life events over the past year at 7 timepoints (18, 30, 42, 57, 69, 81, and 103 months). Study outcomes were prevalence and severity of AD. Median follow-up was 81 months from birth. Those with AD were more likely to be women, have a higher socioeconomic status, and have mothers who experienced more prenatal stress. TAKEAWAY: The annual period prevalence of AD ranged from 18% to 21%, and 5% to 8% of individuals with AD reported having “quite bad” to “very bad disease” at any given timepoint. The most common stressful life events were starting school (91%), starting a new school (75%), pet dying (54%), moving homes (54%), and having a new sibling (45%). Each SD increase in stressful life events was associated with a 4% increase in the odds of active AD (odds ratio [OR], 1.04; 95% CI, 1.01-1.07), with the highest risk for children with moderate to severe AD (OR, 1.13; 95% CI, 1.03-1.23). Of all life events, starting school was associated with a lower risk for active AD (OR, 0.93; 95% CI, 0.88-0.98). Each SD score increase in cumulative stress scores was associated with a higher risk for active AD (OR, 1.11; 95% CI, 1.07-1.16) and severe disease (OR, 1.17; 95% CI, 1.05-1.31). IN PRACTICE: "In a longitudinal, population-based study, we found associations between the perceived impact of childhood stressful life events and AD," the authors wrote. The results “suggest that parents and providers may anticipate and proactively moisturize or treat to prevent potential AD flares around life events," they added, noting that stress-reducing modalities may also be helpful. SOURCE: The study was led by Katrina Abuabara, MD, MA, MSCE, Department of Dermatology, University of California, San Francisco, and was published online on January 28 in the Journal of Investigative Dermatology. LIMITATIONS: Study limitations included potential measurement error and bias in both exposure and outcome. The stressful life events scale used was not independently validated. Caretaker-reported AD activity and severity may have introduced bias. Validated AD severity scores were unavailable for key timepoints. Potential missing data and selection bias were also a concern. DISCLOSURES: The study was supported by the National Institutes of Health and the Wellcome Trust. Abuabara reported receiving consulting fees and grants from pharmaceutical companies. Another author received grants and fellowships from various government organizations; other authors had no disclosures. Note: This article originally appeared on Medscape .

Exposure to officer-involved killings of unarmed Black individuals is associated with worse sleep health among Black adults in the United States, according to new research published in JAMA Internal Medicine. Specifically, Black adults reported significant increases in short and very short sleep following nationally prominent and state-specific officer-involved killings. Previous research has demonstrated racial disparities in sleep health, as Black individuals are more likely to report short sleep durations than White individuals. However, relatively few studies have identified explanations for these disparities. Therefore, the current study examined the extent to which structural racism, in the form of police violence, may contribute to sleep health among Black adults in the US. Researchers gathered individual-level data on sleep duration from 2 nationally representative, cross-sectional surveys: the US Behavioral Risk Factor Surveillance Survey (BRFSS) and the American Time Use Surveys (ATUS). To identify officer-involved killings of unarmed Black individuals, the researchers used information from Mapping Police Violence (MPV), an online database that has tracked officer-involved killings since 2013. The primary outcomes of interest were self-reported total sleep duration (average house of sleep), short sleep (duration <7 hours), and very short sleep (duration <6 hours) among Black adults. For the primary exposure, the researchers used a binary indicator for whether an officer-involved killing of an unarmed Black person occurred in the respondent’s state of residence in four 90-day intervals before the BRFSS or ATUS surveys. Responses from the BRFSS survey included a total of 181,865 Black adults distributed across 50 US states and the District of Columbia and ATUS responses consisted of 9958 Black adults distributed across 44 states and the District of Columbia. For BRFSS and ATUS respondents, the mean duration of sleep was 6.8 (SD, 1.7) and 8.8 (SD, 2.5) hours, 45.9% and 22.6% reported short sleep, and 18.4% and 11.3% reported very short sleep, respectively. Overall, 331 officer-involved killings of unarmed Black individuals were recorded in the MPV database during the study period. Greater than one-third of participants in both surveys (BRFSS, 35.8% vs ATUS, 35.5%) were exposed to an officer-involved killing of an unarmed Black person in their state of residence in the 90 days before their survey interview. The researchers found a 1.3 (95% CI, 0.5-2.2; P =.003) percentage point increase in short sleep and 1.1 (95% CI, 0.13-1.97; P =.03) percentage point increase in very short sleep among Black adults in the 91 to 180 days after officer-killings. When Black adults were exposed to nationally prominent officer-involved killings, these percentage point increases rose to 2.1 (95% CI, 0.02-4.08; P =.047) for short sleep and 2.1 (95% CI, 0.57-3.71; P =.01) for very short sleep. No adverse outcomes on sleep health were found for White respondents exposed to officer-involved killings of unarmed Black individuals. These findings support the notion that sleep health may be influenced by structural racism in the US. Study authors concluded, “These findings further underscore the need for evidence-based institutional reforms to eliminate officer-involved killings in the Black community and other manifestations of biased policing.” The primary limitations of the study include the reliance on self-reported sleep duration rather than polysomnography, potential data inaccuracy from the use of the crowd-sourced MVP database, and a lack of data on the effect of nonfatal police encounters. Note: This article originally appeared on Psychiatry Advisor

Key Takeaways Emergency psychiatry involves complex legal and ethical issues, including patient privacy, autonomy, and safety, requiring careful navigation of HIPAA regulations and ethical principles. Pediatric confidentiality adds complexity, necessitating transparent communication with patients and caregivers about confidentiality limits and safety concerns. Involuntary hospitalization and high-risk discharges require balancing autonomy with beneficence and nonmaleficence, ensuring patient safety and appropriate care. Initiating acute treatment in emergency settings is crucial, with informed consent challenges and the need for flexibility in applying legal and ethical considerations. S PECIAL REPORT: EMERGENCY PSYCHIATRY Emergency psychiatry faces several unique legal and ethical issues given the high stakes of assessing acute lethality, determining disposition often with incomplete information, and interfacing with external stakeholders. The Health Insurance Portability and Accountability Act (HIPAA) often causes legal concerns for clinicians when deciding whether confidentiality can be breached over a patient’s objections. Working with pediatric patients old enough to consent to their own mental health treatment and who ask for privacy adds another layer of complexity. Ethical issues in emergency psychiatry include thoughtful consideration of autonomy, beneficence, and nonmaleficence as they pertain to clinical decision-making, high-risk discharges, initiation of treatment in the emergency setting, and use of restraint and/or seclusion. This article will review key practice points for each of these considerations. Balancing Patient Privacy and Collateral Despite HIPAA’s privacy exceptions, the decision to contact sources of collateral information over a patient’s objection can be a difficult one. Providers may hesitate even to accept information from others. After mass shootings in Aurora, Colorado, and Newtown, Connecticut, in 2012, the Office of Civil Rights released a letter addressed to “our nation’s health care providers” reminding them of privacy exceptions. The letter outlined that clinicians are “presumed to be acting in good faith” if they base their opinion on either direct knowledge or a “credible report from a family member of the patient or other person” and can release information to individuals (eg, family) or entities (eg, law enforcement) who can help mitigate danger posed by the patient to themselves or others. If someone calls with a concern, clinicians can accept information and integrate it into the assessment without releasing information. Disclosures should be limited to the minimum needed to mitigate risk. Patients may not express suicidal or violent intent on interview for a variety of reasons. In fact, Shea wrote in 2009 that “real suicidal intent” equals “stated intent + reflected intent + withheld intent.” A careful interview is essential, but the last 2 elements may hold the key to an accurate assessment. In 2021, Edwards et al acknowledged the critical importance of collateral information regarding withheld intent in a review of the essential role of natural supports in suicide prevention. Collateral information from family or other sources can provide missing puzzle pieces of reflected and withheld intent, allowing for more effective interventions. Pediatric Confidentiality Considerations Clinicians face an ethical challenge when safety concerns involving children and adolescents arise, particularly if these patients have concerns about their parent or guardian learning of these concerns. When individuals present with suicidal or homicidal ideation, self-harm, or other safety concerns, they must undergo a thorough risk assessment, which includes interviewing caregivers. This evaluation may be the first time parents or guardians learn about the child’s emotional distress. Clinicians should be transparent with the individual from the beginning of the interview about the limits of confidentiality, including suicidal and homicidal ideation and alleged abuse. If the adolescent resists sharing safety-related concerns with their parents, the provider should explore these feelings collaboratively and discuss the specific information that will be shared with the parent/guardian. Clinicians can ask the patient how they expect their parent/guardian to react and reassure them that support will be offered during this difficult conversation. It helps to acknowledge and validate that discussing topics such as lethality and self-harm may be uncomfortable but that it is a necessary part of the evaluation process and disposition planning. Creating a space for emotionally safe disclosure is the clinician’s responsibility, ensuring that parents/guardians are informed and can actively participate in safety planning, risk mitigation, and decisions about next steps in care. Health systems face challenges with protecting adolescents’ mental health and substance use information, given that parents may have proxy access to their child’s electronic medical record. In addition, some states have passed a Parents Bill of Rights act, which curtails confidentiality, consent, and privacy rights for adolescents. States also vary on the age required to consent for mental health and substance use treatment. Balancing Autonomy With Beneficence and Nonmaleficence Another common issue that emergency psychiatric clinicians face is the need for involuntary psychiatric hospitalization of patients at imminent risk of self-harm, harm to others, or self- impairment. In many cases, patients will present to emergency services or crisis settings requesting voluntary admission, which is typically legally and ethically straightforward.7 However, there are cases in which it may not be ethically advised to pursue a voluntary admission, even at the patient’s request, as in a patient with secondary gain using the hospital to avoid social stresses or a patient with personality characteristics that have led them to externalize coping in inpatient psychiatric settings as opposed to developing necessary distress tolerance skills. In these cases, clinicians may experience the tension of autonomy vs nonmaleficence, whereby they try to decrease potential iatrogenic harms from patient-requested psychiatric admissions. More commonly, emergency psychiatric clinicians face the issue of patients with limited insight and dangerously impairing symptoms who need to be hospitalized against their wishes. This tension of autonomy vs beneficence, or the need to override the patient’s wishes to do what is medically appropriate, can be difficult but is medically and ethically necessary. In these cases, guaranteeing that clear evidence and indication exist to ensure the patient’s safety and well-being is critical in navigating this ethical tension. There is variance in involuntary commitment criteria between states. Psychiatrists and mental health clinicians should be aware of local involuntary commitment guidelines and procedures. If it is unclear whether involuntary commitment is legally appropriate, providers can consult with the hospital’s legal team. High-Risk Discharges Some patients may clearly benefit from inpatient admission but are unwilling to voluntarily consent, without involuntary commitment grounds being present. In these cases, providers should obtain collateral, thoughtfully discuss and document decision-making, and mitigate modifiable risk factors, eg, via safety planning and reducing access to lethal means. Evidence shows safety plans can help reduce suicidality and improve treatment outcomes. Some patients are at chronically elevated risk of lethality, such as those with repeated suicidal behaviors or a history of violence, who are frequently seen in the emergency psychiatric setting. At times, an acute inpatient psychiatric admission may not be clinically warranted and may actually be countertherapeutic. Clinicians often worry about the risk of adverse patient outcomes and associated litigation, as well as conversations with a patient’s supports on the rationale for discharge. Key components should include engaging the patient and their supports in safety planning and discussing the diagnostic formulation and appropriate treatment options/referrals. Consultation with colleagues, leadership, risk management, and/or legal counsel can be helpful. Organizations can consider patient care plans to help more cohesively care for patients with frequent presentations. Lastly, some patients present with contingency-based suicidal threats. Results of studies have shown that patients who present with contingency-based threats do not appear to be at elevated risk of suicide, although they may have increased emergency department (ED) presentations for self-harm. Bundy et al write that effective documentation surrounding discharge of patients with contingent lethality should contain 6 important items. Initiating Acute Treatment In our current landscape of prolonged boarding for inpatient psychiatric beds, treatment should ideally be initiated in the ED setting and not be deferred to the inpatient teams, as it would for patients presenting with other emergent conditions. Treating substance withdrawal is critical, given the risks of complicated withdrawal (eg, with GABA-mediated agents) and of patients leaving against medical advice. Home medications should be continued in the emergency setting, as missing medications may worsen a patient’s psychiatric symptoms, place them at risk of withdrawal, and/or otherwise negatively affect their health. Patient harm can occur because of the withholding of home medications. At times, obtaining informed consent before initiation of medication or other treatment can be difficult if a patient presents with severe symptoms and lacks decision-making capacity. Capacity has 4 components: (1) expression of a clear and consistent choice, (2) understanding of factual information, (3) ability to manipulate information to make decisions, and (4) appreciation of the current situation and consequences of a choice. Preferably, patients are involved in decisions about medications, including specific agents and routes of medication, thus promoting their autonomy. However, if a patient’s conduct is placing themselves or others at more imminent risk, even if a patient is not providing consent for treatment, beneficence may outcompete patient autonomy. Similarly, patients who refuse treatment after a significant overdose would likely necessitate treatment over objection. In these cases, pursuing an involuntary commitment may be warranted. In nonemergent situations, states differ on what is necessary to provide treatment over objection, so providers should be aware of their individual state laws. Restraints and Seclusion Workplace violence is on the rise, particularly in emergency settings, so early identification of and intervention for escalating agitation are of the essence in maintaining patient, visitor, and staff safety. Many factors can contribute to patient/visitor agitation, including prolonged boarding, unclear wait times or expectations, overstimulation, lack of interaction or structured activities, substance intoxication/withdrawal, and acute psychiatric conditions. As physical interventions increase the risk of patient and staff injury, general principles for agitation management include engaging the patient in verbal de-escalation (including choice of medications) and attempting less restrictive interventions. Organizations can proactively work toward critically appraising and modifying their environments (eg, improving screening of contraband/weapons), and available resources/personnel can provide robust training on verbal de-escalation and physical interventions, ideally via simulation-based education. Because patients and families may pursue legal action for patient injury from a restraint, it is imperative that a restraint technique be continuously re-evaluated with coaching and correction provided. Given disparities in agitation management in the emergency setting, providers should critically appraise the impact of bias in their perception of agitation, which may be partially mitigated via validated agitation rating scales. Although verbal de-escalation and other nonrestrictive interventions are first-line recommendations, as boxer Mike Tyson said, “Everyone has a plan until they get punched in the mouth.” Staff are compelled to immediately intervene when there is imminent risk or assaultive behavior. If restrictive interventions are required, teams should debrief afterward and work toward discontinuing these interventions once it is safe. Concluding Thoughts By the nature of their work, emergency psychiatrists balance various legal and ethical principles in evaluating and caring for patients, such as privacy, autonomy, beneficence, and nonmaleficence. Clinical scenarios are unpredictable and often evolve rapidly, so providers must be cognitively flexible and agile in applying the various legal and ethical considerations presented in this article. Note: This article originally appeared on Psychiatric Times .

I remember what it was like to be a medical student at a well-known cancer hospital where patients were dying of cancer. In life's final stages, it was not uncommon for physicians to increase the dose of morphine ; it alleviated pain, eased labored breathing, and yes, probably hastened the inevitable for patients who were in their final hours. In these scenarios, no one considered this euthanasia, and no one questioned whether it was the right thing to do. Fast-forward to 2023 when the act of a physician hastening a patient's death has become a controversial topic as criteria have expanded. Like all such topics in our polarized society, people aligned on sides, politics, and religion rush to the head of the room, legislation is proposed, and words take on new meanings. If you're in favor of legalization of clinician assistance in a patient's death, the term is medical assistance in dying (MAID). If you're opposed, the term is the more graphic physician-assisted suicide . The scenario is entirely different from what I saw in my medical school rotations decades ago. It's no longer an issue of easing the pain and discomfort of patients' final hours; the question now is whether, faced with a potentially terminal or progressively debilitating physical illness, a patient has the right to determine when, and how, their life will end, and the medical profession is given a role in this. In many places the bar has been further lowered to incorporate nonterminal conditions, and Belgium and the Netherlands now allow physician-facilitated suicide for psychiatric conditions, a practice that many find reprehensible. In these countries, patients may be provided with medications to ingest, but psychiatrists also administer lethal injections. While Belgium and the Netherlands were the first countries to legalize physician-facilitated death, it could be argued that Canada has embraced it with the most gusto; physician-assisted suicide has been legal there since 2016. Canada already has the largest number of physician-assisted deaths of any nation, with 10,064 in 2021 — an increase of 32% from 2020. The Canadian federal government is currently considering adding serious mental illness as an eligible category. If this law passes, the country will have the most liberal assisted-death policy in the world. The Canadian government planned to make serious mental illness an eligible category in March 2023, but in an eleventh-hour announcement, it deferred its decision until March 2024. In a press release, the government said that the 1-year extension would "provide additional time to prepare for the safe and consistent assessment and provision of MAID in all cases, including where the person's sole underlying medical condition is a mental illness. It will also allow time for the Government of Canada to fully consider the final report of the Special Joint Committee on MAID, tabled in Parliament on February 15, 2023." As a psychiatrist who treats patients with treatment-refractory conditions, I have watched people undergo trial after trial of medications while having psychotherapy, and sometimes transcranial magnetic stimulation or electroconvulsive therapy (ECT). The thing that is sustaining for patients is the hope that they will get better and go on to find meaning and purpose in life, even if it is not in the form they once envisioned. To offer the option of a death facilitated by the very person who is trying to get them better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide . Where is the line, one wonders, when the patient has not responded to two medications or 12? Must they have ECT before we consider helping them end their lives? Do we try for 6 months or 6 years? What about new research pointing to better medications or psychedelics that are not yet available? According to Canada's proposed legislation, the patient must be aware that treatment options exist, including facilitated suicide. Physician-assisted suicide for psychiatric conditions creates a conundrum for psychiatrists. As mental health professionals , we work to prevent suicide and view it as an act that is frequently fueled by depression. Those who are determined to die by their own hand often do. Depression distorts cognition and leads many patients to believe that they would be better off dead and that their loved ones would be better off without them. These cognitive distortions are part of their illness. So, how do we, as psychiatrists, move from a stance of preventing suicide — using measures such as involuntary treatment when necessary — to being the people who offer and facilitate death for our patients? I'll leave this for my Canadian colleagues to contemplate, as I live in a state where assisted suicide for any condition remains illegal. As Canada moves toward facilitating death for serious mental illness, we have to wonder whether racial or socioeconomic factors will play a role. Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death? And how do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope? As psychiatrists, we often struggle to help our patients overcome the stigma associated with treatments for mental illness. Still, patients often refuse potentially helpful treatments because they worry about the consequences of getting care. These include career repercussions and the disapproval of others. When this legislation is finally passed, will our Canadian colleagues offer it as an option when their patient refuses lithium or antipsychotics, inpatient care or ECT?

Key Takeaways Improved or sufficient sleep enhances antidepressant response in TRLLD, while persistent insufficient sleep predicts treatment nonresponse. The OPTIMUM trial found no difference in sleep improvement between treatment arms, emphasizing the importance of addressing sleep disturbances. Behavioral interventions like sleep hygiene and CBT-I are recommended for managing sleep issues in older adults with TRLLD. Sedative hypnotics pose risks, and alternative strategies, including low-dose mirtazapine or doxepin, are suggested for sleep management. Patients with treatment resistant late-life depression (TRLLD) were found 3 times more likely to respond to augmenting or switching antidepressant treatments when sleep also improved or sufficient sleep was maintained, in a post-hoc analysis of a trial comparing interventions. “Sleep-related symptoms that are present during treatment for TRLLD may be modifiable factors that play a role in achieving and maintaining depression response,” observed Michael Mak, MD, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, and colleagues. The investigators revisited data from the Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM) trial which compared pharmacotherapeutic strategies for TRLLD, to ascertain whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, or with improved sleep. Mak and colleagues hypothesized that the analysis would show that (1) most participants with TRLLD exhibit reduced sleep, (2) sleep would improve with each of the pharmacotherapeutic strategies, and (3) that improved sleep would be associated with improvement in depression symptoms, while depression would remain treatment resistant if insufficient sleep persisted or worsened. The OPTIMUM trial treatment arms either augmented the current antidepressant with aripiprazole or bupropion, or switched to bupropion; if symptoms did not remit, investigators augmented with lithium or switched to nortriptyline. Depression symptom severity was measured with Montgomery-Asberg Depression Rating Scale (MADRS), with remission defined as a score less than 10. The MADRS sleep item-4 measured insufficient sleep, comparing duration or depth of sleep during treatment for depression with the pattern when well. Adequacy of sleep is rated on a scale of 0 to 6 with higher scores indicating greater sleep disturbance. In the analysis, a score of greater than 2 at both week 0 and week 10 was classified as persistent insufficient sleep (n=164). Scores that increased over the course of treatment and were greater than 2 at week 10 corresponded to worsening sleep; and a decreased score that was less than or equal to 2 at 10 weeks corresponded to improved sleep. Those with scores of less than or equal to 2 at each visit were categorized as having persistent sufficient sleep and served as the comparator group. Insufficient sleep was reported by 51% of participants (n=323) at the start of the trial.They tended to be younger, had fewer years of education, and had higher severity of depression than those with sufficient sleep. At the end of the initial 10-week switch or augmentation treatment, the number of participants reporting insufficient sleep had fallen to 36%, with no associated difference between treatment arms. Mak et al determined that those with persistent insufficient sleep (25%, n=158) and worsened sleep (10%, n=62) were most likely to remain unresponsive to antidepressant treatment. Those who maintained sufficient sleep (26%, n=164) or had improved sleep (25%, n=158) were 3 times more likely to experience improvement in depression, regardless of the switch or augmentation strategy. Independent predictors of treatment nonresponse included persistent insufficient sleep and worsened sleep. The investigators found that approximately one-third of the participants were using sedative hypnotics for sleep or anxiety. They suggest that the risks associated with these medications are likely to outweigh their benefit, even when used for their approved indications. "As such, the treatment plan should include education about the risks of benzodiazepine use in older adults and healthy sleep behaviors, pharmacologic treatment of insomnia or reduced sleep when appropriate, or referrals to behavioral interventions for sleep," Mak et al urge. Accounting for Sleep in Treating Resistant Depression Having associated sufficient and improved sleep with antidepressant response in TRLLD, the investigators considered the long-established bidirectional relationship of sleep disturbance and depression, and implications for treatment. "In most patients, treating the depression with an evidence-based antidepressant is enough to treat all symptoms including the insomnia," study coauthor Benoit Mulsant, MD, Department of Psychiatry, University of Toronto, explained to Psychiatric Times. The association of sufficient sleep with improvement in depression in each of the treatment arms, regardless of using an "alerting" or less sedating antidepressant like bupropion, is notable, Mulsant observed. "Trying to match patient's symptoms (eg insomnia) with adverse effects of a specific antidepressant (eg sedation) does not work," Mulsant commented, citing previous trials."Patients with depression and insomnia do not do better when randomized to a sedating tricyclic antidepressant than to an activating one like bupropion." However, Mulsant acknowleged that sleep disturbance that precedes and persists after onset of depression can require separate attention. "In a subgroup of patients with depression, insomnia predates depression and does not resolve with resolution of other symptoms, so it is important to assess and treat sleep symptoms with sleep hygiene or CBT-I when needed," he suggested. Lead-author Mak elaborated on the approach for these patients. "If a patient with TRLLD still complains of sleep disturbance/insomnia disorder post-antidepressant treatment, they should trial sleep hygiene therapy and CBT for insomnia if available. The residual insomnia is a substantial risk factor for recurrent depression," Mak warned. In their post-hoc analysis of the OPTIMUM trial, the investigators found that loss of a spouse and lower levels of education were risk factors for having sleep disturbance. For these and others at-risk for or experiencing persistent disrupted sleep, the investigators supported particular attention to sleep in managing their depression. "These patients would still be good candidates for sleep hygiene or CBT-I, if needed, Mulsant indicated. "A first-line antidepressant can be augmented with a medication specifically targeting sleep. A good one for older patients would be mirtazapine at low dosage, like 7.5 or 15 mg, because at higher dosage it becomes a sedating antidepressant that many patients do not tolerate." Mak agreed with the recommendation, adding that patients with mild insomnia may benefit from adding low dose doxepin, 3 to 6 mg, at bedtime to buttress sleep maintenance. "Safety outcomes for low dose doxepin in older adults is reassuring," he commented. Mulsant cautioned that additional evaluation may be warranted in some patients presenting with TRLLD accompanied by poor sleep, fatigue, and cognitive impairment for an undiagnosed sleep apnea or a rarer sleep disorder. Mak concurred. "If an elderly treatment resistant depression patient has co-morbid snoring and/or BMI 35 or above, they should be referred for polysomnograpy—given intermediate to high pre-test probability for obstructive sleep apnea. Male sex, sleepiness or fatigue, presence of hypertension, witnessed apnea, and thick neck makes the risk even worse. Continuous positive airway pressure treatment may improve their mood in the context of obstructive sleep apnea.” Note: This article originally appeared on Psychiatric Times.

SAN DIEGO — Frequent distressing dreams are linked to faster biologic aging and an increased risk for premature death, independent of traditional risk factors, new research suggested. Distressing dreams include bad dreams without awakening and/or nightmares with awakening. An analysis of data from more than four large studies in the United States and the United Kingdom found that experiencing distressing dreams at least once a week was significantly associated with aging at both the cellular level and throughout the body, as well as a threefold increased risk for death before age 70. “It’s difficult to prove causation in observational studies, though you can definitely make an association,” lead investigator Abidemi Otaiku, MD, clinical research fellow at Imperial College London, London, England, told Medscape Medical News. He added that if the relationship turns out to be causal, one possible mechanism is that nightmares act as a stressor, negatively affecting the body. Over time, the cumulative effect of frequent bad dreams could lead to the release of cortisol, a stress hormone that may accelerate aging at the cellular level. In addition, disrupted sleep itself is linked to a range of negative outcomes, including a detrimental effect on mental health. “The takeaway message is that people who have more nightmares are aging faster and dying sooner. Nightmares are more important than people realize, and clinicians should ask about them,” said Otaiku, who is also affiliated with the UK Dementia Research Institute. The findings were presented on April 6 at the American Academy of Neurology (AAN) 2025 Annual Meeting. Link to Psychiatric, Neurologic Disorders Otaiku noted that 4%-10% of individuals experience distressing dreams weekly, and 20%-30% experience them every month, and 85% experience them at least once a year. A 2010 study showed that about 45% of the variation in frequency can be explained by genetic factors. These types of dreams have been linked to a variety of mental health concerns, including increased suicide risk. In addition, Otaiku has published recent research that showed a link between distressing dreams and increased risk for Parkinson’s disease (PD) and between these dreams and cognitive decline and risk for dementia. A year later, he reported a significant link between distressing dreams in childhood and an increased risk for cognitive impairment or PD in adulthood. Other studies have linked distressing dreams to conditions such as cardiovascular disease, hypertension, and diabetes. The current study “was created to test the hypothesis that nightmares may contribute to age-related diseases by the cellular aging process. Premature mortality is the ultimate outcome of accelerated aging,” Otaiku said. Accelerated Cellular and Whole-Body Aging The current analysis included data from the Midlife in the United States (MIDUS) study (n = 1660 US adults; 54% men), the Osteoporotic Fractures in Men Study (n = 1427 US adults; 100% men), the Wisconsin Sleep Cohort Study (n = 1109 US adults; 54% men), and the UK Biobank (126,866 UK adults; 40% men). All participants completed baseline questionnaires, which included reporting how often they had trouble sleeping due to bad dreams in the past month. On these responses, participants were categorized into three groups — less than monthly, monthly, or weekly. UK Biobank data provided blood test data on telomere length as an indicator of cellular aging. In the MIDUS study, blood samples were analyzed to derive three epigenetic markers of whole-body aging: DunedinPACE, GrimAge2, and PhenoAge. Mortality data were available for all studies. Participants in the US cohorts were followed for over 19 years, while those in the UK Biobank cohort were followed for more than 2 years. The study’s outcome measures included the rate of cellular aging at baseline, assessed via telomere length; the rate of organismal aging at baseline, based on a composite of three epigenetic markers; and evidence of premature aging in both the pooled US cohort and the UK Biobank cohort. Results showed a significant association between the frequency of distressing dreams and accelerated cellular aging. The telomere length difference Z-score was 0.09 for those with monthly occurrences compared with less than monthly and reached statistical significance at 0.046 for weekly occurrences (P for linear trend < .001). “In other words, the more frequent the nightmares, the shorter the telomeres,” Otaiku said. Distressing dream frequency was also linked to accelerated organismal aging — referring to the overall aging of the body’s systems. The epigenetic aging index difference Z-score was 0.02 for monthly occurrences compared with less than monthly, and a significant 0.52 for weekly occurrences (P for linear trend < .001). More Harmful Than Smoking, Obesity, Hypertension? In the pooled US cohort, 126 premature deaths occurred before age 70 over the 19-year follow-up period. The hazard ratio (HR) for premature mortality was 1.27 among those who experienced monthly distressing dreams, rising to 3.03 for those with weekly occurrences (P for linear trend < .0001). “Those with weekly nightmares had threefold higher risk for premature death,” showing again that the higher the frequency, the higher the adverse outcome was, said Otaiku. In the UK Biobank cohort, 51 premature deaths were recorded over the 2-year follow-up period. The HRs for premature mortality were 1.43 for monthly distressing dreams and 2.65 for weekly occurrences compared with less than monthly (P for linear trend = .004). In addition, 34.2% of the association between distressing dreams and mortality was accounted for by aging, Otaiku noted. After adjusting for genetic, environmental, and lifestyle factors, distressing dreams remained significantly associated with cellular and organismal aging and premature mortality risk (P for linear trend for all, <.05). “Strikingly, the effect size of frequent nightmares was greater than that of current smoking, obesity, and hypertension combined,” Otaiku said. “The associations were independent of and stronger than traditional risk factors for aging and mortality — and are unlikely to be explained by reverse causality,” he added. Otaiku noted that it could be the accelerated aging that explains the link between distressing dreams and later development of neurodegenerative diseases. He added that future studies are now needed into whether treatment of these dreams could reduce the risk for mortality. Awesome, Interesting’ Research During the post-session Q&A, an audience member noted that patients often report more frequent or intense nightmares after starting certain medications and asked whether Otaiku had examined the impact of specific drug classes. Otaiku responded that his study included access to medication data, and he controlled for the use of antidepressants, antipsychotics, and antihypertensives such as beta-blockers. “Even when I controlled for these in my analyses, nightmares were independently linked to these outcomes. Individuals with nightmares do report more psychotropic medication use, but the link between nightmares and these outcomes is independent of their use,” Otaiku said. Session moderator Anne M. Morse, DO, Geisinger Medical Center, Danville, Pennsylvania, described the study as “awesome and so interesting.” “It definitely made me start to think about whether or not there could be any orexigenic link [involved] just because we see nightmare disorders so frequently in narcolepsy and conditions like that,” Morse said. Orexin is a neuropeptide thought to contribute to the regulating and maintaining of sleep/wakefulness states. Note: This article originally appeared on Medscape .

When I spoke at the International Society of Cosmetic Gynecology 2025 World Congress on March 21, I did not mention "cosmetics". Despite the organization’s focus on aesthetics, the unique skills of the members make them particularly suited to correct difficult problems regarding function — both urinary and sexual. These colleagues are adept at correcting conditions ranging anywhere from secondary anorgasmia to clitoral hood phimosis. At least half of their lectures focused on improving function, not aesthetics. I had been invited to speak about the use of formal dynamic systems theory and analysis to improve surgical outcomes. Systems analysis, a framework widely used to improve function in medicine, engineering, and business, can help us understand the complex — a word which most would agree could be used to describe the female orgasm. Understanding Systems in Medicine A system consists of interdependent components working together to produce an effect greater than any one part can produce. Systems medicine, an interdisciplinary approach, seeks to understand and manage complex biological interactions to improve health outcomes. By this definition, all 11 recognized body systems (integumentary, skeletal, muscular, nervous, endocrine, cardiovascular, lymphatic, respiratory, digestive, urinary, and reproductive) function as dynamic networks. Disruptions in one component will limit the function of the entire system. Of the 11, the female orgasm has a component overlap with the reproductive system — but they are not the same. A woman may conceive with anorgasmia, and a woman can also have a strong libido and enjoy multiple orgasms without conceiving a child. One may argue that the reproductive system provides offspring, but without the orgasm system there would be significantly fewer offspring. Yet, conceiving and sexual pleasure are not equal. One may also argue that if we need systems analysis to understand how to breathe and have a bowel movement, we should use system analysis to understand what brings joy and connection and creativity — orgasm. A 2023 study of medical education reported that out of seven medical schools in the Chicago area, only one taught the complete anatomy of the clitoris and how to evaluate female sexual dysfunction. Only one. As medical education starts to catch up with current research and women's legitimate demands for expert attention to their sexual concerns (by at least teaching physicians about comprehensive female anatomy), it may be time to acknowledge that, despite its absence thus far from traditional medical education, the female orgasm is complicated enough to warrant systems analysis, and such analysis first demands an attempt to define the system. If a "female orgasm system" exists, it should meet the same four criteria that define other systems: 1) identifiable components, 2) interdependent interactions, 3) emergent effects beyond any single component, and 4) stability across varied conditions. My efforts over the past 5 years to define the orgasm system and to encourage doctors and therapists to use systems analysis to treat female sexual dysfunction have not been an effort to invent anything; rather, I hope only to point out such a system exists and to offer a starting point for the work of others. Components of the Female Orgasm System To systematically describe female orgasm, we must first define its essential components. Primary Components Brain: The ultimate control center, integrating sensory, hormonal, and psychological inputs Breasts: Responsive to tactile stimulation, contributes to arousal, and affects pituitary function Clitoris: A sensory-dense structure that is integral to orgasm and communicates with the brain through both somatic and autonomic nerves. Labia: Provides protective and sensory functions Genitourinary Complex (GU Complex): Encompasses the vagina, urethra, and pelvic floor with both autonomic and somatic feedback to the arousal centers of the brain Endocrine System: Regulates hormonal influences on arousal and sexual response Spinal Cord and Blood Flow: Essential for neurological transmission, local engorgement, and relay of oxygen and hormones Psychosocial Factors: Emotional, cognitive, and relational influences that modulate the function of the entire body. Secondary Components Each primary structure comprises substructures with specific roles. For instance, the clitoris includes the glans, corpus cavernosum, and spongiosum. The GU complex involves vaginal elasticity and lubrication, while psychosocial factors extend to behavioral and linguistic influences. Feedback Loops in the Orgasm System: A Path to Innovation Dynamic systems operate through reinforcing and balancing feedback loops. In the context of female orgasm: Reinforcing Loops: Positive stimulation (physical or psychological) enhances arousal, further increasing blood flow and sensory feedback, culminating in orgasm. Balancing Loops: Psychological distress, endocrine dysfunction, or neurovascular impairment can counteract this reinforcement, inhibiting orgasmic function. Using systems analysis to consider how the feedback loops of the autonomic nervous system play a crucial role in female orgasm (integrating somatic input from the dorsal clitoral nerve with the autonomic pathways via the cavernous nerves, ganglion innervating the vaginal wall, inferior hypogastric nerve, and the vagus nerve) triggered the idea for the Clitoxin procedure to modulate autonomic input and enhance arousal. Clinical Implications for Treatment: A Systems-Based Diagnostic Framework Understanding an orgasm as a system provides a structured approach to evaluating sexual dysfunction. Consider a patient presenting with dyspareunia and anorgasmia following surgical intervention. First, surgical success does not guarantee orgasmic function. Although anatomical restoration is critical, persistent anorgasmia may stem from endocrine imbalances (eg, hyperprolactinemia, hypothyroidism), vascular limitations, or psychosocial stressors. Rather than relying solely on procedural interventions or sex therapy/counseling, comprehensive assessment and personalized, targeted, systemic corrections can optimize outcomes. Providers also should enhance patient communication and education.A visual model of the orgasm system can aid in counseling patients, emphasizing the multifactorial nature of the sexual response and reducing unrealistic expectations from isolated interventions. Let's Start Recognizing the Female Orgasm as a System When analyzed through the lens of systems medicine, the female orgasm provides a useful framework for refining surgical, medical, and psychosocial therapeutic strategies and for innovating new ideas. Recognizing orgasm as an emergent property of interconnected biological, neurological, and psychosocial factors fosters a more effective and sophisticated patient-centered approach and facilitates communication across specialties. Future research should continue refining this model to improve clinical applications and optimize sexual health outcomes. It is time for the twelfth body system — along with clitoral anatomy — to become part of our medical education. Note: This article originally appeared on Medscape .