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

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

Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type. Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals. Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted. “While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release. “This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added. The findings were published online on December 4 in JAMA Psychiatry . Psychotherapy Uptick Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress. Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted. To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States. The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year. The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access . Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress. Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals. Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively). After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%). A National Priority Adults with higher incomes defined as two to four times the federal poverty level had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%). Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%). In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%). Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits . Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas. The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it. Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic , teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote. “The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson. “Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added. Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals. Study funding was not disclosed. Olfson reported no relevant disclosures. Note: This article originally appeared on Medscape .

Rates of depression and anxiety were significantly higher in people with chronic pain than in those without pain, results of a new meta-analysis and systematic review showed. Prevalence was also higher based on pain type, with higher rates of depression and anxiety among those with fibromyalgia than those with osteoarthritis, investigators found. “The surprising finding is the significant distribution of prevalence in different pain conditions people with certain types of pain are more vulnerable to depression and anxiety, which is important from a clinical perspective,” lead investigator Rachel Aaron, PhD, assistant professor at Johns Hopkins Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, told Medscape Medical News. The findings were published online on March 7 in the JAMA Network Open . Addressing the Gap In previous population studies, prevalence rates of co-occurring chronic pain and anxiety and depression symptoms varied widely. There was the need for a systematic review to synthesize the findings and clearly define the overall impact of chronic pain and co-occurring depression and anxiety. To address the gap, researchers reviewed 376 studies published between 2013 and 2023 with 347,468 adults with chronic pain (excluding chronic headaches) and 160,564 control participants across 50 countries. The mean age of the pain group was 51 years, and 70% were women. Overall, adults with chronic pain were at higher risk for clinical symptoms of depression and anxiety than clinical and nonclinical control individuals. Investigators recorded a pooled prevalence of 39.3% for clinical symptoms of depression (95% CI, 37.3%-41.1%) and 40.2% for clinical symptoms of anxiety (95% CI, 38%-42.4%). This was considerably higher than rates of depression (13.9%) and anxiety (16.4%) reported in the control groups. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis criteria, 37% of adults with chronic pain met diagnostic criteria for major depressive disorder compared with 10.1% in the control group. Generalized anxiety disorder was also more common in the chronic pain group vs the control group (16.7% vs 3.5%, respectively). Importance of Pain Type? Investigators also found that certain types of pain conditions were more strongly associated with depression and anxiety than others. For example, depression and anxiety were higher in people with fibromyalgia than in those with osteoarthritis (54% vs 29.1% and 55.5% vs 17.5%, respectively). “Although we were unable to test directionality of the relationship between chronic pain, depression, and anxiety in the study, one thought is people with fibromyalgia and other nociplastic-related pain conditions are more vulnerable to developing depression and anxiety in the first place, and that could be a factor driving chronic pain,” Aaron said. Prevalence of depression and anxiety was also higher in younger individuals and in women (P < .001 for both), which Aaron said, “replicates what we see in the general population that rates of depression and anxiety are higher in women.” Clinical symptoms of depression were higher among those recruited from clinical settings, while longer pain duration was associated with greater risk for anxiety symptoms . The authors reported high heterogeneity, particularly across subgroup analyses. “What that means is that we cannot say with a great deal of certainty who is more vulnerable to depression and anxiety in chronic pain and why, although we can make some broader generalizations,” Aaron explained. The findings point to the importance of routine screening of depression and anxiety in clinical settings where people with chronic pain are seen, Aaron said. Moreover, “while we highlight that depression and anxiety is high, we don’t want to forget that it is not the case for everybody,” Aaron added, noting that 60% of people with chronic pain did not meet criteria for significant levels of depression and anxiety. Directionality Problems Commenting on the study for Medscape Medical News, Gary Small, MD, chair of Psychiatry at Hackensack University Medical Center, Hackensack, New Jersey, noted that the finding that rates of depression and anxiety varied based on pain type was particularly interesting. “With arthritis, there are recognized underlying pathological processes; anxiety and depression rates were lower. But, in people with diffused pain from fibromyalgia, where you cannot locate source of pathology, depression, and anxiety rates were higher,” Small said. “This suggests a feedback mechanism between the mental experience and physical source of pain. You get anxious about your pain, and when you don’t understand where it is coming from, it makes feelings of depression and anxiety worse,” said Small, who was not involved in the study. Christina Lee, MD, psychiatrist and medical director of Mental Health Services at Kaiser Permanente in Baltimore, felt the large dataset of nearly 350,000 patients across 376 studies was both a strength and limitation. “While it provides robust evidence for the link between chronic pain and mental health, the high variability across studies makes it difficult to draw precise conclusions. Some studies used self-reported symptoms, while others relied on clinical diagnoses, leading to inconsistencies in measurement,” she said. She also noted that the actual rate of diagnosed psychiatric disorders was lower. “Are we underdiagnosing these conditions, or are symptoms fluctuating rather than meeting full clinical criteria?” she asked. “This study does not establish causation. Does chronic pain trigger depression, or do mood disorders exacerbate pain perception?” Lee said. Note: This article originally appeared on Medscape .

One movie that I think was very fascinating is a movie called Happy , which is available on Netflix. It is documentary film directed, written, and co-produced by Academy Award nominated film-make Roko Belic. It discusses principles of happiness, particularly through the perspective of positive psychology, through a series of interviews of people from 14 different countries, with varying cultural, socioeconomic differences. This was created based on Belic’s interest in trying to understand the fundamental aspects of happiness, which stem from a article he read “A New Measure of Well Being From Happy Little Kingdom” , which indicated that the US was the 23rd happiest country in the world. I am not sure how this ranking was measured. Belic spent several years, meeting hundreds of people, to explore his own curiosity of what factors lead to someone being happy. The film helps deconstruct happiness from an abstract concept to a possible formula based on the principles of human psychology. It was interesting because many of the aspects of happiness that were discussed coincide with concepts that were discussed by Abraham Maslow’s hierarchy of needs illustrated below. Maslow’s theory suggests that the most basic level of needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs. Maslow also coined the term “ metamotivation ” to describe the motivation of people who go beyond the scope of the basic needs and strive for constant betterment. The movie reflects, that regardless of socioeconomic factors and wealth, a individual was capable of feeling happy if he/she were capable advancing their life according the hierarchy that had been stated by Maslow. I thought this was an interest parallel which was not discussed in the movie, however coincided. I think in many ways I believe that Maslow’s hierarchy applies to my life, where I try to focus on my health first and foremost. Source: Medium, Author Vilash Reddy, MD

For adults with ADHD, DBT as a treatment strategy demonstrated superior acceptability to clinical management with placebo. A randomized controlled study published in Psychotherapy and Psychosomatics found that dialectical behavior therapy (DBT) demonstrated acceptability as a treatment strategy for adults with attention-deficit/hyperactivity disorder (ADHD), even in the long term. However, future interventions should target treatment adherence to maximize clinical outcomes. When ADHD persists in adulthood, symptoms can affect educational attainment and social and occupational functioning. Adults with ADHD have reported that cognitive behavioral therapy (CBT) and DBT are useful interventions, but few studies have focused on acceptability and adherence to treatment. The Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS; ISRCTN54096201) was a 4-arm study conducted between 2007 and 2013 that compared DBT-based group therapy plus methylphenidate (GBT+MPH) with DBT-based group therapy plus placebo (GBT+PLB), clinical management plus methylphenidate (CM+MPH), and clinical management plus placebo (CM+PLB). The DBT intervention comprised 12 weekly sessions followed by 10 monthly sessions lasting 120 minutes that covered mindfulness, behavior analysis, emotional regulation, impulse control, stress management, and self-respect modules, among others. The clinical management intervention was delivered in 15- to 20-minute individual sessions following the same schedule as DBT and involved supportive counseling to encourage patients to develop coping skills. For this study, researchers evaluated self-reported efficacy of the treatment and adherence, measured by session attendance. The researchers randomly assigned participants to receive GBT+MPH (n=107), GBT+PLB (n=109), CM+MPH (n=110), and CM+PLB (n=107). These cohorts comprised 47.7%, 45.9%, 50.9%, and 54.2% women; were 34.9, 35.6, 35.6, and 34.9 years of age on average; 62.6%, 51.4%, 53.6%, and 62.6% had combined ADHD; and 50.5%, 53.2%, 50%, and 52.3% had used medication treatments for their ADHD, respectively. At week 52, the researchers found that the overall self-reported effectiveness of treatment was significantly greater for CM+MPH than CM+PLB (P <.001), for GPT+PLB than CM+PLB (P <.001), and for GPT+MPH than CM+PLB (P <.001). The patients who received methylphenidate reported significant effects from medication compared with placebo recipients at weeks 52 and 130 (all P £.019). Notably, recipients of DBT with or without active pharmacotherapy reported significant effects from the therapy intervention compared with CM+PLB at week 52 (both P £.002). Among the DBT recipients, self-reported use of skills was associated with significant improvements in Clinical Global Impression (CGI) scores (P <.001), Conners’ Adult ADHD Rating Scale (CAARS) total scores (P <.05), and CAARS ADHD index scores (P <.05). However, the researchers observed no significant group differences in subjective adherence to or effectiveness of overall skills between the GPT+MPH and GPT+PLB groups (all P ³.061). Additionally, the number of unexcused absences from treatment sessions was higher for GPT+PLB than CM+MPH (P =.013) and CM+PLB (P =.028). Consequently, the researchers found that the number of unexcused absences was negatively correlated with the use of skills overall (r = -0.212) and the use of mindfulness (r = -0.194), emotional regulation (r = -0.174), impulse control (r = -0.181), and relationship/self-esteem (r = -0.173) skills. Study authors concluded, “These findings suggest that improving adherence to therapy skills could enhance treatment response.” These study findings may be limited, as the patients who were lost to follow-up were younger and had more severe illness than those who remained in the study. This article originally appeared on Psychiatric 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 .

Key Takeaways GLP-1 receptor agonists effectively manage obesity, reducing appetite and achieving weight loss in patients with BMI ≥30 or ≥27 with comorbidities. The Confusion Assessment Method is optimal for diagnosing delirium, while the Geriatric Depression Scale is sensitive for detecting depression in older adults. Collaborative care models between family medicine and psychiatry enhance patient outcomes by addressing both physical and mental health needs. Reducing stigma and integrating behavioral health services in family medicine can improve access to psychiatric care. CONFERENCE SPOTLIGHT The Spotlight series highlights speakers at the Family Medicine Experience 2024 (FMX 2024), hosted by the American Academy of Family Physicians. Name Ecler Jaqua, MD, MBA, FAAFP, AGSF, FACLM, DipABOM, AAHIVS Title Associate Professor Institution Loma Linda University Hometown Pomona, CA Tell us about yourself. I am an associate professor of family medicine at Loma Linda University Health, specializing in family medicine and geriatrics. My work is driven by a passion for holistic and comprehensive care, ensuring the well-being of my patients across different stages of life. In addition to my clinical practice, I enjoy teaching and mentoring the next generation of physicians, and I have completed certifications in lifestyle medicine, obesity medicine, and HIV specialization. I am also actively involved in program leadership and quality improvement initiatives. Can you please discuss some key take home points from your presentation at the FMX 2024 conference? At the FMX conference, I presented on 2 key topics. First, I discussed the role of GLP-1 receptor agonists in managing obesity, emphasizing their ability to reduce appetite and achieve significant weight loss in patients with a body mass index greater than or equal to 30 or greater than or equal to 27 with comorbidities like type 2 diabetes. I also covered protocols for initiating treatment and managing adverse effects. In my second topic, I compared cognitive screening tools, highlighting the Confusion Assessment Method as the best tool for diagnosing delirium, while the Geriatric Depression Scale is highly sensitive for detecting depression in older adults . Do you have any suggestions for improving the integration between family medicine and psychiatry to enhance patient care? Improving integration between family medicine and psychiatry can be achieved by fostering collaborative care models where mental health professionals work closely with family physicians to address both physical and mental health needs. Regular interdisciplinary case reviews, shared care plans, and streamlined referral processes can enhance patient outcomes, ensuring timely and holistic treatment for conditions like depression, anxiety, and chronic illnesses with mental health components. Additionally, training family physicians in primary care psychiatry can help bridge the gap in access to mental health services . What do you believe to be some factors that prevent patients from seeking help at times from a psychiatrist? Any suggestions for improvement? Patients may avoid seeking help from a psychiatrist due to stigma surrounding mental health, fear of being judged, or a lack of understanding about psychiatric care. Limited access to services and financial concerns can also be barriers. To improve this, increasing mental health education, normalizing conversations about mental health in primary care settings, and integrating behavioral health services within family medicine can help reduce stigma and improve access to psychiatric care. How do you deal with patient compliance and managing adverse effects from various psychiatric medications? Managing patient compliance and adverse effects from psychiatric medications involves open communication, educating patients about potential adverse effects, and setting realistic expectations about treatment outcomes. I regularly assess patients for tolerance and adherence, adjusting medications as needed to minimize side effects while maintaining effectiveness. Collaborative decision-making, involving patients in their treatment plans, also helps improve compliance and addresses any concerns early on. What advice about patient care would you like to share with your medical colleagues in psychiatry? For my colleagues in psychiatry, I would emphasize the importance of maintaining a patient-centered approach by fostering trust and open dialogue. Collaborating with other health care providers, particularly in primary care, can provide a more comprehensive understanding of the patient’s overall well-being, improving outcomes. Any words of wisdom or favorite quotes? One of my favorite quotes is: "The good physician treats the disease; the great physician treats the patient who has the disease." – William Osler. Another quote I value is, "People don’t care how much you know until they know how much you care." – Theodore Roosevelt. This serves as a reminder that compassion and empathy are foundational in building strong patient relationships and delivering effective care. Note: This article originally appeared on Psychiatric Times .

Key Takeaways Negative symptoms in schizophrenia, including diminished expression and apathy, are challenging to treat and often resist conventional antipsychotics targeting positive symptoms. Distinguishing primary from secondary negative symptoms is crucial, as secondary symptoms may arise from factors like medication side effects or comorbid conditions. Pharmacological treatments, such as cariprazine and clozapine, show potential but require more evidence from randomized controlled trials. Nonpharmacological interventions, including TMS and digital phenotyping, offer promising avenues for addressing negative symptoms in schizophrenia. Emerging treatments, like psychedelics, are being investigated for their potential benefits, though their use remains controversial and requires further research. Schizophrenia is a frequently chronic and disabling disorder, marked by heterogeneous positive and negative symptom constellations. While antipsychotic medications usually manage positive symptoms effectively, there are limited treatment options for negative symptoms. Despite progress in understanding schizophrenia’s etiology, biology, and psychopharmacology, negative symptoms remain an unmet medical need. Negative symptoms pose significant challenges for individuals with schizophrenia and their caregivers. These symptoms can be described in 5 factors. These symptoms severely impair daily functioning and can be resistant to conventional antipsychotic treatments, which primarily target positive symptoms by modulating dopamine pathways in the brain. From a phenomenological point of view, negative symptoms can be described within 2 dimensions: (1) the dimension of diminished expression, comprising alogia and blunted affect; and (2) the dimension of apathy, comprising avolition, asociality, and anhedonia. These 2 distinct dimensions are thought to have different underlying neurobiological mechanisms. Distinguishing primary negative symptoms from secondary negative symptoms is therefore an essential part of the treatment approach. Primary negative symptoms are thought to be intrinsic to the underlying pathophysiology of schizophrenia, while secondary negative symptoms are thought to be related to other factors. These factors include positive symptoms, treatment adverse effects (sedation, extrapyramidal symptoms, akathisia), anxious and depressive symptoms, environmental deprivation, substance use, other comorbid psychiatric disorders, and medical comorbidities. For instance, investigators describe a complex relationship between negative symptoms and depression in schizophrenia . Indeed, affective symptoms are commonly observed in nonaffective psychosis, affecting 50% to 80% of patients at some point during their illness. Primary evidence indicates that low mood, suicidal thoughts, and pessimism are more specifically linked to depression, while alogia and blunted affect are more closely associated with negative symptoms. Nevertheless, anhedonia, anergia, and avolition may be present in both conditions. Therefore, a thorough evaluation of clinical symptoms in individuals with schizophrenia is essential to accurately identify their nature and tailor the treatment accordingly. The causes of depressive symptoms in schizophrenia are diverse, including dysphoria induced by antipsychotic medications, psychological stressors, stigma, and traumatic life events. Addressing these causes requires a combination of nonpharmacological and pharmacological approaches. In this specific case, a switch to an antipsychotic with antidepressant properties should be considered. Add-on antidepressant is another potential option, as are cognitive behavior therapy sessions. Pharmacologic Treatments Another important point is the need to avoid first-generation antipsychotics, as these dopamine antagonists present a significant risk of inducing secondary negative symptoms due to their dose-dependent adverse effects: sedation, extrapyramidal symptoms, lower motivation, and mood. Regarding second-generation or third-generation antipsychotics, there is limited evidence based on very few randomized controlled trials (RCTs). Although amisulpride selectively blocks dopamine D2 and D3 receptors, at low doses (50 to 300 mg/day) it preferentially blocks presynaptic dopamine receptors, which may enhance dopaminergic transmission in pathways associated with negative symptoms. This contrasts with higher doses, at which it blocks postsynaptic receptors to alleviate positive symptoms. Cariprazine is also promising for the treatment of predominant and persistent negative symptoms. This second-generation antipsychotic has demonstrated efficacy in reducing negative symptoms. It acts as a partial agonist at dopamine D2 and D3 receptors with a higher affinity for D3 receptors, which are believed to play a significant role in cognitive and emotional processes. Clinical trials have shown that cariprazine not only improves positive symptoms but also has a significant impact on negative symptoms. However, current evidence is limited to a few RCTs published by the same manufacturer. Clozapine is another second-generation antipsychotic. Although clozapine presents a weak affinity for D2 receptors and antagonizes D1 and D4 receptors, it is thought to regulate glutamatergic neurotransmission, which can be beneficial for negative symptoms in schizophrenia, particularly secondary negative symptoms related to treatment-resistant positive symptoms or comorbid depression. Its efficacy for primary negative symptoms is less clear, with some studies showing modest benefits. Novel mechanism-of-action (MOA) agents such as pimavanserin are emerging for treatment of both positive and negative symptoms of schizophrenia with very interesting results. Pimavanserin is a selective serotonin 5-HT2A agonist/antagonist and a 5-HT2C receptor antagonist. In a phase 2 trial, stable patients with predominant negative symptoms of schizophrenia showed a reduction in negative symptoms after treatment with pimavanserin. However, only a small effect size was found. Therefore, further investigation with optimized dosing is warranted to determine the clinical significance of this effect. Overall, for pharmacological approaches, there is a lack of high-level evidence supporting specific interventions. Further research is necessary before recommending amisulpride or cariprazine as a treatment for negative symptoms in clinical practice. Nonpharmacological Treatments Nonpharmacological treatment methods have been found to be effective in the treatment of patients with undifferentiated negative symptoms of schizophrenia. For instance, patients with negative symptoms should have access to rehabilitation interventions such as supported employment and supported housing. We present in the Figure a decision tree for current recommendations of the treatment of negative symptoms in individuals with schizophrenia. Recent advancements in medical research have introduced potential novel treatments aimed at addressing these debilitating negative symptoms, offering new hope for improving the quality of life for those affected by this condition. The add-on of psychostimulants to concurrent antipsychotics has been studied, with various RCTs with modafinil and armodafinil. However, only limited improvement for patients with predominant negative symptoms has been found to date, which precludes current recommendation in clinical practice, pending further research. Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain. Research has shown that TMS can be effective in reducing negative symptoms by targeting specific brain regions involved in mood and cognition. Although many RCTs have been published, there is significant heterogeneity among included patients and stimulation parameters used. Nevertheless, in expert centers, treatment with left prefrontal repetitive TMS can be considered for patients with negative symptoms that do not improve with other interventions. Original and very recent interventions are starting to be proposed to target negative symptoms in individuals with schizophrenia, such as the use of specific serotonergic psychedelics. Arnovitz et al propose 3,4-methylenedioxymethamphetamine (MDMA) as a novel therapeutic given its ability to enhance social interactions, generate empathy, and induce a state of metaplasticity in the brain. MDMA has been shown to be an effective treatment for posttraumatic stress disorder. An open-label, ascending-dose, within-subject trial of MDMA (dose, 40-120 mg) is being conducted in the US for individuals with schizophrenia presenting negative symptoms (NCT05770375). Psilocybin, a serotonergic psychedelic, also exhibits entactogenic properties and may be of interest in addressing the negative symptoms of schizophrenia . However, the psychedelic experience or “trip” associated with these substances is controversial when considering their use as potential add-on therapies as they may trigger adverse effects in individuals with schizophrenia. Moreover, most second-generation antipsychotics (eg, risperidone, olanzapine) act as “trip stoppers,” preventing patients from experiencing the psychedelic effects that might be beneficial. Furthermore, the combination of first-generation antipsychotics with psychedelics could amplify the effects of the psychedelics, increasing the risk of worsening adverse symptoms in patients.16 It remains an open question whether the psychedelic trip is necessary to achieve the antidepressant effects of these substances. Husain et al proposed an innovative double dummy trial in patients with treatment-resistant depression to try to answer to this question. However, certain antipsychotics, such as amisulpride at moderate doses (eg, 400 mg), could theoretically be used to prevent a potential increase in positive symptoms following psychedelic use while still allowing the psychedelic experience to occur. Nevertheless, switching a stable patient’s antipsychotic regimen to accommodate the potential benefits of an add-on psychedelic treatment is also a matter of debate. Finally, the assessment of negative symptoms is also evolving with promises from digital phenotyping, offering a more precise and continuous method of monitoring than traditional assessments. By leveraging data from smartphones, wearable devices, and other digital tools, digital phenotyping can capture subtle behavioral and physiological changes that may indicate the presence or severity of negative symptoms, such as social withdrawal, reduced motivation, and diminished emotional expression. This real-time, objective data can complement clinical evaluations, providing a more comprehensive understanding of a patient’s condition and enabling personalized treatment approaches. Additionally, digital phenotyping can help in early detection of symptom exacerbation, potentially leading to timely interventions that improve outcomes for individuals with schizophrenia. Concluding Thoughts In sum, negative symptoms in schizophrenia represent a significant challenge, both in terms of patient suffering and the limitations of current treatment approaches. While advancements in pharmacological and nonpharmacological treatments show promise, particularly with novel interventions like digital phenotyping,novel MOA agents, and psychedelics, much remains to be understood and validated through rigorous research. Note: This article originally appeared on Psychiatric Times .

Antidepressant ARCELONA — The typical lag between treatment initiation with selective serotonin reuptake inhibitors (SSRIs) for depression and enhanced mood may be because of the time it takes to increase brain synaptic density, new imaging data suggest. In a double-blind study, more than 30 volunteers were randomly assigned to the SSRI escitalopram or placebo for 3-5 weeks. Using PET imaging, the investigators found that over time, synaptic density significantly increased significantly in the neocortex and hippocampus but only in patients taking the active drug. The results point to two conclusions said study investigator Gitta Moos Knudsen, MD, PhD, clinical professor and chief physician at the Department of Clinical Medicine, Neurology, Psychiatry and Sensory Sciences, at Copenhagen University Hospital, Copenhagen, Denmark. First, they indicate that SSRIs increase synaptic density in brain areas critically involved in depression, a finding that would go some way to indicating that the synaptic density in the brain may be involved in how antidepressants function, "which would give us a target for developing novel drugs against depression," said Knudsen. "Secondly, our data suggest synapses build up over a period of weeks, which would explain why the effects of these drugs take time to kick-in," she added. The findings were presented here at the 36th European College of Neuropsychopharmacology (ECNP) Congress, and simultaneously published online in Molecular Psychiatry . Marked Increase in Synaptic Density SSRIs are widely used for depression as well as anxiety and obsessive-compulsive disorder. It is thought they act via neuroplasticity and synaptic remodeling to improve cognition and emotion processing. However, the investigators note clinical evidence is lacking. For the study the researchers randomly assigned healthy individuals to either 20-mg escitalopram or placebo for 3-5 weeks. They performed PET with the 11C-UCB-J tracer, which allows imaging of the synaptic vesicle glycoprotein 2A (SV2A) in the brain, synaptic density, as well as changes in density over time, in the hippocampus and neocortex. Between May 2020 and October 2021, 17 individuals were assigned to escitalopram and 15 to placebo. There were no significant differences between two groups in terms of age, sex, and PET-related variables. Serum escitalopram measurements confirmed that all participants in the active drug group were compliant. When synaptic density was assessed at a single time point, an average of 29 days after the intervention, there were no significant differences between the escitalopram and placebo groups in either the neocortex ( P = .41) or in the hippocampus ( P = .26). However, when they performed a secondary analysis of the time-dependent effect on SV2A levels, they found a marked difference between the two study groups. Compared with the placebo group, participants taking escitalopram had a marked increase in synaptic density in both the neocortex ( rp value, 0.58; P = .003) and the hippocampus ( rp value, 0.41; P = .048). In contrast, there were no significant changes in synaptic density in either the neocortex ( rp value, -0.01; P = .95) or the hippocampus ( rp value, -0.06; P = .62) in the hippocampus. "That is consistent with our clinical observation that it takes time to evolve synaptic density, along with clinical improvement. Does that mean that the increase in synaptic density is a precondition for improvement in symptoms? We don't know," said Knudsen. Exciting but Not Conclusive Session co-chair Oliver Howes, MD, PhD, professor of Molecular Psychiatry, King's College London, London, United Kingdom, agreed that the results do not prove the gradual increase in synaptic density the treatment response lag with SSRIs. "We definitely don't yet have all the data to know one way or the other," he told Medscape Medical News . Another potential hypothesis, he said, is that SSRIs are causing shifts in underlying brain circuits that lead to cognitive changes before there is a discernable improvement in mood. Indeed, Howes suggested increases in synaptic density and cognitive changes related to SSRI use are not necessarily dependent on each other and could even be unrelated. Also commenting on the research, David Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology at Imperial College London, United Kingdom, said that the "delay in therapeutic action of antidepressants has been a puzzle to psychiatrists ever since they were first discerned over 50 years ago." "So, these new data in humans, that use cutting edge brain imaging to demonstrate an increase in brain connections developing over the period that the depression lifts, are very exciting." Nutt added the results provide further evidence that "enhancing serotonin function in the brain can have enduring health benefits." Funding support was provided by the Danish Council for Independent Research, the Lundbeck Foundation, Rigshospitalet, and the Swedish Research Council. Open access funding provided by Royal Library, Copenhagen University Library. Knudsen declares relationships with Sage Biogen, H. Lundbeck, Onsero, Pangea, Gilgamesh, Abbvie, and PureTechHealth. Another author declares relationships with Cambridge Cognition, and PopReach via Cambridge Enterprise. 36th European College of Neuropsychopharmacology (ECNP) Congress. Abstract S14.04 and P.0378. Presented October 8 and 9, 2023.

Key Point: The context and timing of symptoms is critical for a timely and accurate bipolar diagnosis. CLINICIAN’S CORNER “Knowledge without context is confusion.” -Chuck D, Public Enemy Understanding the context and timing of symptoms is critical to making a timely and accurate bipolar diagnosis. Unfortunately, the context and timing of symptoms are often overlooked. The delay from onset of symptoms to bipolar diagnosis is 10 years on average. This underdiagnosis or delay of diagnosis of bipolar has often been made when the person's index presentation for psychiatric evaluation is during a depressive episode. Every person presenting with symptoms of depression must be, at a minimum, evaluated for previous symptoms of mania or hypomania (occurring in the absence of substance use) and familial history of bipolar illness. Understanding the broader context of the person's presentation and not accepting depressive symptoms at face value can reduce diagnostic errors and delays in appropriate medication management. Underdiagnosis and overdiagnosis of bipolar illness can both be attributed to inadvertently dismissing or attributing symptoms that occur during teen years and early 20s (the average age of onset for bipolar illness) as developmentally normal. It is important to determine that the presenting symptoms are a stark change from baseline.1 Late adolescence and early adulthood are times when impulsivity, irritability, risk-taking, poor sleep, and recreational substance use are pervasive. Data are trending towards a recent phenomenon of overdiagnosis of bipolar illness in certain settings.2-4 Anecdotally, some argue that the increase is not due to incorrect diagnosis or overdiagnosis, but an increase in appropriate screening. Others have balked at the increase and attributed the trend to undue patient influence via Google and wholesale misdiagnosis. Although not diagnostic, validated screening instruments can help frame the conversation of presenting symptoms and ensure that important context is not overlooked. Screenings are not diagnostic. In psychiatry, clinicians often fall into 2 categories: those who use validated screening instruments and those who do not. Research indicates that less than 20% of behavioral health practitioners utilize measurement-based care.5 The low utilization of rating scales is multi-factorial. It includes provider concerns for patient confidentiality, competing requirements of insurance and medical records, and a belief that clinical judgment is suitable.5 Using clinical judgment alone, providers detected early deterioration in only 21.4% of patients.6 Clinical incorporation of measurement-based care may reduce deterioration by 4% to 8% and improve positive outcomes.7 Self-report patient assessments are a valuable tool, but these rating scales must be seen as the first step in a 2-stage process. If the screening is positive, a more definitive and extensive evaluation is warranted. A good screening instrument will detect almost all patients with the disorder (high sensitivity) and rule out the disorder for almost all patients who screen negative (high negative predictive value). While high specificity or high positive predictive value is less critical for screening, an effective screener helps clinicians identify almost all patients who need further evaluation for the disorder. To reduce false positive diagnoses, clinicians must uphold screening as a 2-stage process. In busy clinical practices, it is tempting to take a positive screener as diagnostic confirmation. One of the great challenges for patients and clinicians alike is the prevalence of cooccurring substance use for those living with bipolar illness. Current literature has a prevalence of cooccurring substance use ranging from 30% to 50%.1,8 If we can ascertain that the timing and context of symptoms were present before the substance use then the bipolar diagnosis is not complicated to make; however, the timing and context are often not so clearly defined. Further, other differentials and comorbidities such as borderline personality disorder and attention-deficit/hyperactivity disorder (ADHD) must also be ruled out. There are other contextual clues that can further inform our differential in the absence of clear history of manic or hypomanic features. A few scenarios that would prompt medication management consistent with the treatment for bipolar illness rather than unipolar depression (mood stabilizers and dopamine receptor blocking agents vs SSRI/SNRI), despite not meeting all DSM-5 diagnostic criteria: Patient has the genetic pedigree of multiple first and second-degree relatives with type 1 bipolar illness and reports the first onset of depression at age 8 in the absence of any lifetime trauma, bullying, or loss. Patient has a history of postpartum depression and an immediate response (within 48 hours) to an SSRI. That is not to say that these scenarios then rate a bipolar diagnosis; they do not. The patient must continue to be followed, and the longitudinal monitoring of symptoms noted. The context suggests that there is high suspicion for bipolar illness and the patient would likely benefit from a more nuanced approach to their medication management. Reducing false positives in the diagnosis of bipolar disorder requires careful consideration and implementation of key principles. Although bipolar disorder carries distinct diagnostic criteria, clinicians may misdiagnose a patient due to phenomenological overlap with other symptoms. For instance, patients misdiagnosed with bipolar disorder are more likely to carry features of borderline personality disorder. A comprehensive assessment, utilizing a semi-structured clinical interview remains the gold standard for the diagnosis of bipolar disorder. However, busy clinicians may have to balance thorough clinical assessments against practice settings with limited time and resources. Self-report rating scales can help clinicians identify patients who require a more thorough assessment. Another key principle in reducing the misdiagnosis of bipolar disorder is to reject the pressure to assign a bipolar diagnosis immediately. Mania/hypomania is rarely an index presentation in bipolar disorder. This means that most patients will present in psychiatric clinics with complaints of depression that are indistinguishable from unipolar depression. Longitudinal monitoring of patients’ symptoms can provide clarity of diagnosis. For example, if the patient’s cognitive complaints are persistent regardless of affective state, this may suggest a comorbid psychiatric diagnosis while cognitive dysfunction within the context of a mood episode may be suggestive of bipolar illness. Lastly, clinicians should take care to remember that medication response is not diagnostic. Often, clinicians may update a diagnosis based on a response to a new medication class. For example, a positive response to lithium augmentation in a refractory depression may tempt a new diagnosis of bipolar disorder in light of this positive response. Lithium and second-generation antipsychotics are effective augmenting agents in unipolar depression.10 Clinicians may also be tempted to convert to a bipolar diagnosis if a patient experiences irritability or agitation with an antidepressant trial. The use of antidepressants does not convey any diagnostic implications unless the patient experiences a manic switch.11 One of the more significant updates to bipolar diagnostic criteria between the DSM-IV to DSM-5 is the inclusion of antidepressant-induced mania as diagnostically sufficient provided that it is temporal and persists at a fully syndromal level.12 An antidepressant-induced manic episode is one of the few circumstances where a diagnostic change is informed by medication response. Just as bipolar disorder is both overdiagnosed and underdiagnosed, psychiatry has a similar relationship with diagnostic fidelity. In school, students are often taught a rigid adherence to diagnostic criteria, but early career clinicians frequently enter a clinical environment of ambiguity, symptom overlap, and diagnostic uncertainty. Early career clinicians must understand how diagnosis informs treatments, prognosis, and nearly every other aspect of care. Psychiatry remains a field of syndromes, meaning a group of signs and symptoms with known associated features that characterize a particular disorder. In the absence of biomarkers or other definitive testing, a careful and accurate diagnosis remains one of the most critical components of psychiatry. There has been increasing awareness and attention spent on the underdiagnosis of bipolar disorder. A delay in bipolar diagnosis may contribute to many adverse outcomes. However, our efforts to increase awareness of bipolar disorder must not overcorrect. Overdiagnosis of bipolar disorder poses significant challenges in mental health care , leading to inappropriate treatment and mismanagement of other underlying conditions. By understanding the limitations of screening instruments, recognizing the impact of comorbidities, and adhering to key principles in diagnostic assessment, clinicians can improve diagnostic accuracy. A careful and nuanced approach ensures that individuals receive appropriate and effective care, tailored to their specific needs. Note: This article originally appeared on Psychiatric Times .

Keypoint: Recent updates in suicide prevention interventions for older adults and how a novel tablet application may provide relief to individuals at high risk of suicide. Suicide in late life constitutes a major public health concern. In 2019, the Centers for Disease Control and Prevention (CDC) reported that the suicide rate for all ages in the United States was 14.5/100,000. Middle-aged and older adults have higher rates of suicide than their younger counterparts (19.41/100,000 for individuals aged 55 to 64), and the highest rate of suicide remains for older males (39.9/100,000 for males aged 75 and older).1 Despite the alarmingly high rates, psychosocial interventions for this population are understudied and urgently needed. Mobile devices provide a unique and powerful opportunity to deliver interventions to suicidal individuals during periods of increased suicide risk.2 With the current COVID-19 pandemic , reliance on digital health technology is growing, and developing targeted interventions that can be used remotely by older adults during times of emotional crisis is of paramount importance. Characteristics and Risk Factors To establish effective psychosocial interventions, risk factors for late-life suicide must be examined. Sociodemographic and clinical factors that are more commonly found in middle-aged and older individuals (eg, widowhood, cognitive decline, etc) play an important role in suicide risk . Understanding the complex interaction of these late-life occurrences can guide efforts in designing preventative interventions. Demographic Factors According to the CDC, middle-aged and older adults account for the highest number of suicides compared to younger populations. In 2018, adults aged 65 and older were reported to make up 16% of the US population, but were responsible for 18.8% of suicides. While there are an estimated 25 suicide attempts for every completed suicide in the general population, approximately 1 in 4 suicide attempts results in death for older adults. Gender, race, and ethnicity also influence suicide risk and behavior. Women consistently account for a higher number of suicide attempts than men. There are 3 female attempts for each male attempt, yet an estimated 3.6 males die by suicide for every 1 female death. This discrepancy is attributed to the difference in method, because men often use more lethal methods when attempting suicide. In comparison to other racial and ethnic groups, non-Hispanic American Indian/Alaska Native and non-Hispanic white people account for the highest rates of suicide at 22.3 and 17.6/100,000, respectively. Cognitive Functioning and Physical Illness As many as 1 in 9 older adults suffer from some form of cognitive impairment. Cognitive impairment is often responsible for reducing decision-making capacity and affecting emotion regulation abilities, potentially contributing to suicidal ideation and behavior. Discrepancies in literature regarding suicide risk and cognitive impairment suggest that dementia can either be a risk factor or a protective factor depending on the progression and severity of symptoms. However, a review on suicide risk and Alzheimer disease found that Alzheimer disease is associated with a moderate suicide risk in older adults, even several years after diagnosis. Physical illness and functional disability in late life are also strongly associated with suicide. In a cohort study by Erlangsen and colleagues,12 investigators found that certain cancers and liver disease, specifically, are most closely associated with suicidal outcomes. Despite strong associations found in research, reviewers of the literature advise caution when using physical illness to determine risk, many noting that identifying physical illness does not serve as a predictor for suicide, nor does quantifying the severity of symptoms. Psychiatric Illness and Suicidal Behavior Psychiatric illness is noted in up to 97% of late-life suicides, with major depression cited as the most strongly associated psychiatric disorder. Retrospective analysis of psychiatric illness and suicide mortalities in older adults in Denmark highlight recurrent depression as contributing to the highest rate of suicides in adults aged 60 and older, followed closely by other affective disorders and reaction to stress/adjustment disorders. This risk was significantly increased for individuals who were hospitalized for any type of psychiatric disorder, with hospitalized psychiatric illness accounting for 22.3% of male suicides aged 60 and older. One of the predictors of suicidal behavior is suicidal ideation, especially active suicidal ideation with intent or plan. However, in older adults who are seeking aging services, even passive suicidal ideation is an indicator of suicide risk. Despite the elevated number of late-life suicides, suicidal older adults often go undetected due to lower rates of reporting, especially in primary care where older adults most likely seek medical treatment. This information highlights the need for increased identification strategies, as well as enhanced efforts to prevent the onset of suicidal ideation given the high mortality rate in late-life suicide attempters. Psychosocial Factors Interpersonal losses including widowhood or death of friends and family are commonplace in advancement of age. The accompanying stress, sense of loneliness, and social disconnection in response to loss is associated with elevated suicide risk, especially within the first year after the death of a close relative. Passive and active suicidal thoughts are particularly common among older adults in long-term care facilities, and social isolation and loneliness are some of the most frequently reported bases for suicidal thoughts. The relationship between perceived social support and psychiatric illness, most notably depression, is strong even when controlling for other factors, such as negative affectivity and overreporting of experiences. This points toward a need for more dynamic psychosocial interventions. Existing Psychosocial Interventions for Suicide Prevention Current randomized, controlled trials (RCTs) that evaluate psychosocial interventions for older adults are typically developed to address depression or other affective disorders in young adults and are not specifically targeted toward suicidality. Of the few published RCTs that measure suicidal ideation as a primary outcome in older adults, the intervention and assessment methods are diverse. Conwell investigated the effect of a peer companionship program on socially disconnected older adults, but saw no significant difference in suicidal ideation outcomes between the treatment and control groups. Two studies, conducted by Ecker and Kumpula, evaluated adaptations of CBT on veterans with suicidal ideation. The first study was a 4-month brief cognitive behavioral therapy (CBT), and the second was CBT for depression compared against 2 other evidence-based psychotherapies. Both authors reported a reduction in suicidal ideation in the CBT/bCBT groups compared to control groups. Gustavson and Lutz examined suicidal ideation as a primary outcome in tests of problem-solving therapy in older adult populations. These studies both saw significant reductions in suicidal ideation in the treatment groups; however, 1 study tailored the intervention toward older adults with depression and executive dysfunction, and the other targeted subjects with functional disability, making the interventions difficult to compare. Kiosses investigated the effects of problem adaptation therapy (PATH) on suicidal ideation, an intervention that utilizes emotion-regulation techniques and compensatory strategies in older adults with depression and cognitive impairment. The authors saw a reduction in suicidality in the PATH participants, but the reduction was not significantly different from the supportive therapy control group. The samples in the aforementioned studies represent specific populations (ie, veterans with medical illness, older adults with functional disabilities), and are not representative of the general older adult population. The heterogeneity of the interventions creates difficulty in both between-study comparisons and generalizability to the general population. Moreover, these studies often exclude those who express active suicidal ideation, leaving out those who are at greater risk of suicide. The results are promising; however, it is important that findings be replicated with larger and more representative samples to more accurately examine the effectiveness and promote generalizability of the interventions. Role of Technology in Treatment The onset of the COVID-19 pandemic and the associated policies have the potential to exacerbate the severity of the previously identified risk factors for suicide in older adults. Social-distancing guidelines, stress, and limited access to health care may contribute to increased feelings of isolation and loneliness, worsening of cognitive and functional abilities, and intensification of symptoms of psychiatric disorders. Technology offers the opportunity to alleviate logistical barriers to receiving clinical interventions for older adults who may have difficulty adhering to treatment. As the reliance on telehealth increases, more thorough investigation into remote psychosocial intervention methods targeted specifically for this population is particularly essential. Literature on the role of technology treatment for suicide prevention in older adults is sparse. Preliminary findings available on feasibility and acceptability of technology-based mobile interventions suggest promising effects of improvement, but further testing is needed. In a review of mobile health technology for suicide prevention, one intervention, Virtual Hope Box (VHB), was tested in middle-aged adults. The study recruited both young and middle-aged veterans with a mean age of 46 years old and tested an augmentation of CBT using smartphone capabilities to enhance and personalize the experience with a “hope box.” The study evaluated the effect of the application on intensity of suicidal ideation and importance of reasons for living, but the results yielded no statistically significant treatment effect on these outcomes between the treatment and control groups. Our research at the Emotion, Cognition, and Psychotherapy Lab at Weill Cornell Medicine aims to reduce suicide risk by employing a simplified, personalized, and easy-to-use mobile intervention. WellPATH is a tablet application that focuses on emotion regulation strategies (specifically, cognitive reappraisal strategies, which focus on seeing a situation from a different perspective) to reduce negative emotions associated with increased suicide risk. It is a personalized, mainly standalone, mobile intervention that incorporates patient-specific techniques that can be accessed when the patient is faced with negative emotions. The patient and WellPATH interventionist identify situations, problems, or concerns that trigger intense negative emotions that may lead to increased suicidal ideation or behavior and develop personalized cognitive reappraisal strategies to reduce the intense negative emotions. Preliminary results indicate that patients are able to utilize the user-friendly interface with ease and are highly satisfied with the support provided by WellPATH. The WellPATH application takes into consideration characteristics unique to older adults and offers immediate access to an intervention that is easy to use. It addresses the need for a mobile suicide prevention intervention for middle-aged and older adults at high suicide risk, which is particularly germane, given the increased reliance on telehealth . Concluding Thoughts The topic of suicide in older adults requires greater consideration. Identification of risk factors is valuable in understanding elder suicidality; however, further attention is encouraged for the development and evaluation of effective interventions tailored to older adults. The few psychosocial interventions mentioned show overall promising results, but unfortunately, there is little available data beyond what has been described. The novel WellPATH tablet application has the opportunity to provide relief to individuals at high risk of suicide by offering an immediate intervention to patients in their actual environment. With the rapid increase in population of middle-aged and older adults, the continued exploration of adaptive preventative interventions is essential for safeguarding the well-being of this increasingly vulnerable population. Note: This article originally appeared on Psychiatric Times .